Virtual Ed - General

Clinician Specialty: General Practitioner Telehealth consultation Id Check - 3 points, Name, DOB, address Consent to AI for note taking Subjective - Reasons for visit and chief complaints: Patient presents with a 3-day history of persistent headache and mild nausea. - Duration, timing, location, quality, severity, and context of the complaint: Headache started approximately 72 hours ago, constant, dull, located across the forehead and temples. Severity rated 6/10, worse with bright lights and noise. Nausea is intermittent, not leading to vomiting. No clear precipitating event. - Aggravating and alleviating factors: Aggravated by screen time and sudden head movements. Partially alleviated by lying down in a dark room and over-the-counter paracetamol (which provides temporary relief for about 2-3 hours). - Symptom progression: Headache initially mild but has gradually worsened over the past 3 days. Nausea developed yesterday. - Past occurrences of similar symptoms: Reports similar, less severe headaches in the past, usually relieved by rest and hydration. No prior history of headaches with associated nausea. - Functional impact: Symptoms are affecting concentration at work (remote desk job) and sleep quality. Has missed a day of work due to symptoms. - Associated symptoms: Reports photophobia and phonophobia. Denies fever, stiff neck, visual changes, or neurological deficits. Allergies: Penicillin (rash), Ibuprofen (stomach upset) Medications: Paracetamol PRN for headache, Multivitamin daily Past Medical History: - Past medical and surgical history: No significant past medical history. No prior surgeries. - Family history: Mother has a history of migraines. Father has hypertension. - Exposure history: No recent travel or known exposure to sick contacts. - Immunisation history and status: Up-to-date with routine immunisations, including recent flu jab and COVID-19 boosters. - Other relevant subjective information: Reports increased stress levels recently due to work deadlines. Social history: - Social history: Non-smoker, rarely vapes. Consumes alcohol socially, 2-3 units per week. Works as a software developer. Lives with partner. Objective: - Vital signs: BP 120/78 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.8°C, O2 Sat 98% on room air. - Physical or mental state examination findings: Appears slightly fatigued but alert and oriented. Cranial nerves intact. No focal neurological deficits noted. Neck supple with full range of motion, no tenderness. No skin rashes. Pupils equally reactive to light. - Completed investigations and results: None prior to this consultation. Assessment: - Likely diagnosis: Tension-type headache with migraine features. - Differential diagnosis: Migraine, sinusitis, medication overuse headache, early viral illness. Patient has confirmed understanding of diagnosis, plan and safety netting. Plan: - Planned investigations: None immediately planned. Will consider blood tests (FBC, ESR, CRP) if symptoms persist or worsen significantly. - Planned treatment: Recommend rest, adequate hydration. Advise trial of naproxen 500mg BD for 3 days, given ibuprofen allergy. Suggest warm compresses to the forehead. Advise managing screen time and stress. - Other relevant actions: Provide headache diary template. Safety netting advice given regarding worsening headache, development of fever, stiff neck, visual changes, or focal neurological symptoms – advised to seek urgent medical attention if any occur. Follow-up consultation scheduled in 5 days, or sooner if symptoms do not improve.