History:
- Reason(s) for consultation, including specific neurological concerns or symptoms such as headache, seizures, weakness, numbness, tingling, movement disorders, memory loss, etc.: Patient presents with complaints of chronic headaches and occasional dizziness.
- Detailed history of the presenting complaint(s), including onset, duration, severity, pattern of symptoms, aggravating/alleviating factors, associated neurological or systemic symptoms, any previous treatments and responses.: Headaches started approximately 6 months ago, occurring 2-3 times per week. Described as a throbbing pain, primarily in the frontal region, lasting for several hours. Aggravated by stress and lack of sleep. No known triggers. Patient has tried over-the-counter pain relievers with limited relief.
Past History:
- Past medical and surgical history, highlighting any previous neurological diagnoses, brain or spinal surgeries, hospitalizations, outcomes, etc.: No prior neurological diagnoses. No history of brain or spinal surgeries. No hospitalizations.
- Social history, focusing on lifestyle factors, occupation, smoking, alcohol use, recreational drug use, etc.: Patient is a non-smoker. Drinks alcohol occasionally. Works as a software engineer.
- Family history: Mother has a history of migraines.
Medications:
- Current medications, including any neuro-specific medications, over-the-counter medications, supplements, etc.: Ibuprofen 200mg as needed for headaches.
Allergies
- Allergies, including allergies to medications (especially those affecting the nervous system), etc.: No known drug allergies.
Examination
- Vitals: BP 130/80, HR 78, RR 16, Temp 37°C
- Physical examination findings, including general examination and focused neurological examination assessing mental status, cranial nerves, motor system (strength, tone), sensory system, reflexes, coordination, gait, etc.: General: Alert and oriented. Neurological: Cranial nerves II-XII intact. Motor strength 5/5 in all extremities. Sensory intact to light touch and pinprick. Reflexes 2+ and symmetrical. Coordination intact. Gait normal.
- Investigations with results, including laboratory tests, imaging tests, electrodiagnostic tests (e.g., EEG, EMG), etc.: MRI brain without contrast performed, results pending.
Impression:
1. Neurological Issue or Condition
- Assessment, including the likely diagnosis and rationale based on subjective and objective findings with a focus on neurology.: Probable diagnosis: Tension-type headache. Rationale: Based on the patient's description of the headache characteristics, frequency, and lack of other neurological symptoms.
- Differential diagnosis.: Migraine, Cervicogenic headache, Sinus headache.
Plan:
- Investigations planned, including any imaging, electrodiagnostic testing, lumbar puncture, etc.: Review MRI brain results.
- Medical treatment planned, including details such as medication, dosage, expected outcomes, potential side effects, etc.: Discussed preventative medications for headaches, such as amitriptyline. Patient to start amitriptyline 10mg at night, increase to 25mg after one week if tolerated. Expected outcome: Reduction in headache frequency and severity. Potential side effects: Drowsiness, dry mouth.
- Lifestyle modifications, including sleep hygiene, stress management, dietary advice, etc.: Advised patient on stress management techniques and sleep hygiene.
- Mention any referrals to specialties or services.: No referrals needed at this time.
- Follow-up appointments, covering the expected timeline for review, monitoring response to treatment, and adjustment of management plans.: Follow-up in 4 weeks to assess response to treatment.
Additional Notes:
- Patient education on the diagnosed condition, including explanation of the neurological disorder, its impact on daily life, potential complications, and the importance of treatment adherence.: Explained the nature of tension-type headaches and the importance of medication adherence.
- Instructions for monitoring and managing symptoms, including when to seek urgent care for symptoms such as sudden worsening of condition, new seizures, or signs of stroke.: Instructed patient to seek immediate medical attention if they experience a sudden, severe headache, new neurological symptoms, or changes in vision.
- Any specific patient or family concerns addressed during the consultation.: Addressed patient's concerns about the potential side effects of amitriptyline.
This set of notes has been produced with the assistance of an AI-scribing service. I confirm that verbal consent has been obtained from the patient. I have reviewed the content of notes and confirm that these are a full and accurate record of my clinical assessment. Date: 1 November 2024
History:
- [Reason(s) for consultation, including specific neurological concerns or symptoms such as headache, seizures, weakness, numbness, tingling, movement disorders, memory loss, etc.] (Only include reasons for consultation or neurological concerns if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Detailed history of the presenting complaint(s), including onset, duration, severity, pattern of symptoms, aggravating/alleviating factors, associated neurological or systemic symptoms, any previous treatments and responses.] (Only include detailed history of presenting complaints if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Past History:
- [Past medical and surgical history, highlighting any previous neurological diagnoses, brain or spinal surgeries, hospitalizations, outcomes, etc.] (Only include past medical and surgical history if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Social history, focusing on lifestyle factors, occupation, smoking, alcohol use, recreational drug use, etc.] (Only include social history if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Family history] (Specify which family members have particular conditions or other history of note. Only include if family history is explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Medications:
- [Current medications, including any neuro-specific medications, over-the-counter medications, supplements, etc.] (Only include current medications if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Allergies
- [Allergies, including allergies to medications (especially those affecting the nervous system), etc.] (Only include allergies if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Examination
- [Vitals] (Only include [vital signs] if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Physical examination findings, including general examination and focused neurological examination assessing mental status, cranial nerves, motor system (strength, tone), sensory system, reflexes, coordination, gait, etc.] (Only include physical examination findings if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Investigations with results, including laboratory tests, imaging tests, electrodiagnostic tests (e.g., EEG, EMG), etc.] (Only include investigation results if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Impression:
[1. Neurological Issue or Condition] (Write as a numbered list starting from 1 and add more numbered items as needed.)
- [Assessment, including the likely diagnosis and rationale based on subjective and objective findings with a focus on neurology.] (Only include assessment and rationale if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own assessment or diagnosis.)
- [Differential diagnosis.] (Only include differential diagnosis if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own differential diagnosis.)
[2. Additional Neurological Issues or Conditions] (Write as a numbered list continuing from previous section with numbered items.)
- [Follow the same structure as above for each additional issue or condition identified.] (Only include additional neurological issues or conditions if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
(Never come up with your own assessment or plan, always use the transcript and contextual notes for this.)
Plan:
- [Investigations planned, including any imaging, electrodiagnostic testing, lumbar puncture, etc.] (Only include investigations planned if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Medical treatment planned, including details such as medication, dosage, expected outcomes, potential side effects, etc.] (Only include medical treatment plan if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own medical treatment plan.)
- [Lifestyle modifications, including sleep hygiene, stress management, dietary advice, etc.] (Only include lifestyle modifications if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never suggest your own lifestyle modifications.)
- [Mention any referrals to specialties or services.] (Only include referrals if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Follow-up appointments, covering the expected timeline for review, monitoring response to treatment, and adjustment of management plans.] (Only include follow-up appointments if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
(Never come up with your own assessment or plan, always use the transcript and contextual notes for this.)
[Additional Notes:]
- [Patient education on the diagnosed condition, including explanation of the neurological disorder, its impact on daily life, potential complications, and the importance of treatment adherence.] (Only include patient education if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Instructions for monitoring and managing symptoms, including when to seek urgent care for symptoms such as sudden worsening of condition, new seizures, or signs of stroke.] (Only include symptom management instructions if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Any specific patient or family concerns addressed during the consultation.] (Only include specific patient or family concerns if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
This set of notes has been produced with the assistance of an AI-scribing service. I confirm that verbal consent has been obtained from the patient. I have reviewed the content of notes and confirm that these are a full and accurate record of my clinical assessment.
