PPDC New Patient/Consult

Clinician Specialty: Nurse Practitioner HPI: Mrs. Eleanor Vance presents today as a new patient for evaluation of persistent headaches and chronic fatigue. She reports experiencing dull, throbbing headaches primarily in her temples and forehead that started approximately six months ago and have gradually worsened. The headaches occur almost daily and are rated 6/10 on a pain scale, occasionally reaching 8/10 with associated photophobia and phonophobia. She has tried over-the-counter ibuprofen and paracetamol, which provide only minimal and temporary relief. The fatigue is described as constant and debilitating, impacting her ability to perform daily activities and work. She sleeps approximately 7-8 hours per night but wakes feeling unrefreshed. She denies any recent trauma, fever, or visual changes. Subjective: Mrs. Vance, a 48-year-old female, is here for her initial consultation regarding her ongoing headaches and fatigue. She expresses significant concern about the impact these symptoms are having on her quality of life and her role as a primary caregiver for her elderly mother. She reports that the headaches are often exacerbated by stress and loud noises. Her past medical history includes mild hypertension, diagnosed five years ago, currently managed with medication, and a cholecystectomy performed ten years ago without complications. She takes Amlodipine 5mg once daily for her blood pressure and occasionally takes a multivitamin. She denies any herbal supplements. Mrs. Vance is a non-smoker, rarely consumes alcohol (socially, 1-2 units per month), and works as an administrative assistant. She lives with her husband and mother. She reports no known allergies. Assessment: Problem List: 1. Chronic Migraine (G43.709) 2. Chronic Fatigue Syndrome (R53.82) 3. Essential (primary) Hypertension (I10) Tests, Labs and Imaging Results: * Complete Blood Count (CBC): Within normal limits (WNL). * Basic Metabolic Panel (BMP): WNL. * Thyroid Stimulating Hormone (TSH): WNL. * Vitamin D levels: Slightly low at 20 ng/mL. * MRI Brain: No acute intracranial pathology or structural abnormalities noted. Plan: - Problem 1: Chronic Migraine - Initiate Topiramate 25mg daily, titrate up to 50mg daily after one week, as tolerated, for migraine prophylaxis. - Prescribe Sumatriptan 50mg as needed for acute migraine attacks, up to two doses per 24 hours. - Advise on identifying and avoiding potential triggers (e.g., caffeine, certain foods, stress). - Recommend maintaining a headache diary to track frequency, severity, and potential triggers. - Problem 2: Chronic Fatigue Syndrome - Recommend Vitamin D supplementation with 2000 IU daily and recheck levels in three months. - Encourage regular, gentle exercise, starting with short walks and gradually increasing duration. - Advise on sleep hygiene practices, including maintaining a consistent sleep schedule and creating a conducive sleep environment. - Refer to cognitive behavioral therapy (CBT) for fatigue management. - Problem 3: Essential Hypertension - Continue Amlodipine 5mg daily. - Advise on regular home blood pressure monitoring. - Recommend dietary modifications (reduced sodium intake, increased fruits and vegetables). - Follow up in 3 months to reassess blood pressure control and overall progress.