Subjective:
- Patient presents with a chief complaint of a persistent headache, described as a dull ache located in the frontal region, which began approximately 2 weeks ago. The headache is intermittent, occurring several times a week, and lasts for several hours each time. Associated symptoms include mild sensitivity to light and occasional nausea.
- Patient reports a history of hypertension, diagnosed 5 years ago, which is well-managed with medication. The hypertension does not significantly impact daily activities.
- No history of previous TIAs or strokes.
- Patient has an upcoming appointment with a cardiologist next month.
Objective:
- Blood pressure: 130/80 mmHg, Pulse: 78 bpm, Temperature: 37°C.
- Neurological examination reveals normal power, sensation, and movements in all extremities and the face.
- No joint range of motion limitations or pain reported.
Assessment & Plan:
1. Headache
- Possible tension headache or migraine. Rule out other causes.
- Advised patient to keep a headache diary to track frequency, triggers, and severity.
- Discussed over-the-counter pain relief options.
- Scheduled a follow-up appointment in 2 weeks.
2. Hypertension
- Confirmed diagnosis of hypertension.
- Continue current medication regimen.
- Advised patient on lifestyle modifications, including diet and exercise.
- Monitor blood pressure regularly at home.
- Reviewed the importance of medication adherence.
- Provided counselling on the risks of uncontrolled hypertension.
3. Past TIA
- Not applicable.
4. Upcoming Cataract Surgery
- Not applicable.
5. Current Medications
- Amlodipine 5mg daily for hypertension.