Follow-Up Consultation

Specialty: Neurologist Subjective: Patient, Mr. Arthur Jenkins, a 68-year-old male, reports continued headaches, though less severe than previously. He describes them as a dull ache, located bifrontally, occurring 3-4 times a week, down from daily. He notes improved sleep quality since starting amitriptyline 10mg nightly, with no reported side effects. He states he has been compliant with medication as prescribed. His functional status remains good; he is able to perform daily activities without significant limitations. He denies any new visual disturbances, motor weakness, or sensory changes. Objective: Vital signs: BP 130/80 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.8°C. General physical exam unremarkable. Neurological examination reveals intact cranial nerves, symmetrical motor strength 5/5 in all extremities, normal tone, sensation intact to light touch and pinprick bilaterally, and deep tendon reflexes 2+ bilaterally at biceps, triceps, patella, and Achilles. Plantar responses are flexor. Gait is steady with no ataxia. Romberg test negative. Imaging: A recent MRI of the brain (dated 28 October 2024) shows no acute pathology, stable chronic microvascular changes. Laboratory results (dated 29 October 2024) including complete blood count and metabolic panel are within normal limits. Assessment: Mr. Jenkins presents with chronic daily headache, now improving, likely tension-type headache with a migraine component, well-controlled on current medication. He demonstrates good response to amitriptyline with reduced frequency and intensity of headaches. No signs of disease progression or complications. His neurological status remains stable. Plan: 1. Continue amitriptyline 10mg nightly. 2. Consider increasing amitriptyline to 20mg nightly if headaches worsen or if he desires further reduction in frequency/intensity, provided no new side effects develop. 3. Recommend maintaining a headache diary to track frequency, intensity, and potential triggers. 4. Patient educated on non-pharmacological headache management strategies, including stress reduction and regular exercise. 5. Follow-up in 3 months or sooner if symptoms significantly change or worsen. Refer to headache specialist if conservative management fails.