New clinic patient

Diagnosis: The patient presents with a primary diagnosis of migraine with aura, characterised by recurrent episodes of severe headache accompanied by visual disturbances, including flashing lights and blurred vision. Differential diagnoses considered include cluster headaches and tension-type headaches, but the patient's symptoms and history are most consistent with migraine with aura. Plan: The management plan includes the initiation of prophylactic medication, specifically topiramate, at a starting dose of 25mg daily, to be increased to 50mg daily after one week if tolerated. The patient is advised to keep a headache diary to monitor the frequency and severity of headaches. Follow-up appointments are scheduled for 4 weeks to assess the efficacy of the medication and discuss any side effects. The patient is educated on lifestyle modifications, including stress management techniques and avoiding known triggers. Referral to a neurologist is made for further evaluation and management. Previous Medical History: The patient has a history of childhood asthma, which is currently well-controlled with an as-needed inhaler. There is no history of previous surgeries or hospitalizations. Family history is significant for migraines in the patient's mother. Medications: * Sumatriptan 50mg, as needed for acute migraine attacks. * Salbutamol inhaler, as needed for asthma. Write a detailed summary of the medical consultation, explaining the patients symptoms and medical history Examination: Neurological examination revealed normal cranial nerves, motor strength, and sensory function. Reflexes were symmetrical and physiological. Cerebellar function was intact. No focal neurological deficits were identified. Summary: Dr. Thomas Kelly explained to the patient that the diagnosis is migraine with aura, and the plan is to start prophylactic medication, topiramate, and to monitor the frequency and severity of headaches with a diary. A follow-up appointment is scheduled in four weeks to assess the efficacy of the medication and discuss any side effects. The patient was also advised to manage stress and avoid known triggers. The patient was also referred to a neurologist for further evaluation and management. The patient was advised to take sumatriptan 50mg as needed for acute migraine attacks and to use their salbutamol inhaler as needed for asthma. The date of this consultation was 1 November 2024.