Multiple Problem-Based Consultation Note

Specialty: General Practitioner Problem #1: Chronic Migraines Chief Complaint: Persistent, severe headaches affecting daily activities. History of Present Illness: Patient reports a 6-month history of chronic migraines, occurring 15-20 days per month. Pain is described as throbbing, unilateral, 7/10 in severity, often associated with photophobia and phonophobia. Migraines are typically preceded by an aura of flickering lights. Aggravating factors include stress and lack of sleep. Relieved slightly by over-the-counter ibuprofen, but efficacy is decreasing. Patient is currently taking sumatriptan 50mg as needed, but finds it less effective recently. Patient smokes 5 cigarettes per day and consumes alcohol socially (2-3 units per week). Lives with partner in a detached house. Mother has a history of migraines. Known drug allergies: Penicillin (rash). Physical Examination and Review of Systems: General: Alert and oriented, no acute distress. Neurological: Cranial nerves II-XII intact, no focal neurological deficits, deep tendon reflexes 2+ bilaterally, sensation intact. No signs of meningism. Vital Signs: BP 120/80 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.8°C. Assessment: 1. **Chronic Migraine without Aura**: Justified by frequent, severe headaches with typical migraine features and decreasing response to acute treatment. 2. **Medication Overuse Headache (MOH) secondary to Sumatriptan**: Justified by increasing frequency of migraine attacks and decreasing efficacy of sumatriptan, a triptan often implicated in MOH when used frequently. Plan: Treatment: Initiate Topiramate 25mg daily, titrating up to 50mg daily over two weeks, for migraine prophylaxis. Discussed importance of limiting acute migraine medication use to no more than 2-3 days per week to prevent MOH. Advised on stress management techniques and consistent sleep hygiene. Recommended smoking cessation. Provided patient with information leaflet on migraine management. Investigations: Bloods ordered: Full blood count, electrolytes, liver function tests (due to Topiramate initiation). Follow-up: Return in 4 weeks to review Topiramate efficacy and tolerability, and discuss progress with acute medication reduction. Problem #2: Mild Anxiety History of Present Illness: Patient reports feeling increasingly anxious over the past 3 months, particularly regarding work-related stress and the frequency of her migraines. Experiences difficulty sleeping, occasional heart palpitations, and general unease. Denies panic attacks or suicidal ideation. No previous psychiatric history. No relevant social factors beyond general work stress. No relevant family history. No known drug allergies. Physical Examination and Review of Systems: General: Appears slightly restless, but cooperative. Cardiovascular: S1S2 normal, no murmurs. Vital Signs: BP 120/80 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.8°C (as above, but pertinent for anxiety context). Assessment: 1. **Generalized Anxiety Disorder, mild**: Justified by persistent worry, difficulty controlling worries, and associated physical symptoms impacting daily function over several months. Plan: Treatment: Advised on relaxation techniques and mindfulness exercises. Provided patient with details for local counselling services. Recommended engaging in regular physical activity. Discussed the interplay between chronic pain and anxiety. Investigations: None currently indicated. Follow-up: Encouraged to book a follow-up appointment if anxiety symptoms worsen or if she wishes to discuss further treatment options, including pharmacotherapy, after attempting initial self-management strategies.