NWNTPCN Template (eGP)

Clinician Specialty: Healthcare Service Manager Current issues, reasons for visit, history of presenting complaints: Patient presents with a 3-week history of persistent headache, visual disturbances, and intermittent nausea. They express concerns about the impact on their daily work and family life. Any other associated symptoms: Reports occasional dizziness and difficulty concentrating. Past Medical History: Medical history: Hypertension, diagnosed 5 years ago, well-controlled with medication. No history of migraines. Surgical history: Appendectomy at age 12. Family history: Mother had a history of vascular headaches. Medications: Lisinopril 10mg once daily. Denies use of over-the-counter pain relievers for current symptoms. Social history: Non-smoker, rarely consumes alcohol (socially, 1-2 units per month). Works as an accountant, often working long hours in front of a computer. No illicit drug use. Allergies: Penicillin (rash). Exam findings Vital signs: Pulse 72 bpm, Blood Pressure 130/85 mmHg, Temperature 36.8°C, Respiratory Rate 16 breaths/min, Oxygen Saturation 98% on room air. Physical or mental state examination findings, including system-specific examination(s): General: Appears well, slightly anxious. Neurological: Cranial nerves intact, no focal neurological deficits. Normal gait and coordination. Negative for nuchal rigidity. Ophthalmic: Pupils equal, round, reactive to light and accommodation. Funduscopic exam unremarkable. Mental State: Alert and oriented to person, place, and time. Affect appropriate to mood. No overt signs of distress. Impression & Plan: 1. Issue, problem or request 1: Persistent Headache with Visual Disturbances Impression, likely diagnosis for Issue 1: Tension-type headache with migraine features Differential diagnosis for Issue 1: Migraine with aura, secondary headache (e.g., related to hypertension, intracranial pathology - though less likely given normal neurological exam) Investigations planned for Issue 1: Full blood count, electrolytes, liver and renal function tests. Consider referral for an MRI brain if symptoms persist or worsen. Treatment planned for Issue 1: Paracetamol 1g PRN for headache, maximum 4 doses daily. Advised on stress reduction techniques and regular breaks from screen time. Discussed potential for triptans if diagnosis of migraine is confirmed. Relevant referrals for Issue 1: Potential referral to Neurology if symptoms do not improve within 2 weeks or if MRI is indicated. 2. Issue, problem or request 2: Anxiety regarding symptoms Impression, likely diagnosis for Issue 2: Health anxiety Differential diagnosis for Issue 2: Generalised anxiety disorder, adjustment disorder Investigations planned for Issue 2: None at present. Treatment planned for Issue 2: Reassurance provided regarding initial assessment findings. Advised on mindfulness exercises. Consideration of talking therapies if anxiety becomes debilitating. Relevant referrals for Issue 2: Referral to Psychological Therapies Service if anxiety significantly impacts quality of life. Summary: Patient presented with a multi-symptom complaint of headache, visual disturbance, and nausea, alongside associated anxiety. Initial assessment points towards a tension-type headache with migraine features and health anxiety. Management includes symptomatic treatment, lifestyle advice, and monitoring for further investigation or specialist referral if required. The patient was advised on when to seek further medical attention. Safety net such as any specific follow-up details or when to contact the practice or other healthcare services: Patient advised to contact the practice if headache worsens, new neurological symptoms develop, or if initial treatments are ineffective. Follow-up appointment scheduled in 2 weeks to review symptoms and investigation results.