EMIS Consultation Record

Specialty: General Practitioner Problem: New onset headache, Fatigue, Stress-related anxiety History: Onset 2 weeks ago, gradual progression. Headache described as a dull ache, worse in the evenings. Associated with generalised fatigue, impacting daily activities. Patient reports increased work-related stress over the past month. No fever, visual changes, or neurological deficits. Denies recent head trauma. Currently taking paracetamol occasionally for headache relief with limited effect. Examination: No examination performed today. Family History: Mother has a history of migraines. Father has a history of hypertension. Social: Works full-time as an accountant, often working long hours. Lives with partner and two children. Reports moderate alcohol intake (4-5 units/week) and no smoking. Has not been exercising regularly due to fatigue. Comment: 1. New onset headache: Advised to keep a headache diary. Consider paracetamol PRN, review effectiveness. If symptoms persist or worsen, consider further investigations. 2. Fatigue: Discussed sleep hygiene, advised regular exercise (when able) and balanced diet. Offered blood tests for FBC, Ferritin, TFTs, U&Es. 3. Stress-related anxiety: Discussed relaxation techniques and mindfulness. Provided information on local stress management resources. Advised to book a follow-up appointment in 2 weeks to review symptoms and blood results. Suggested SNOMED Codes: * Headache * Fatigue * Stress * Anxiety