Headache

Patient Name: John Doe

Date of Birth: 03/10/1970

Gender: Male

MRN #: 123456789

Date of Service: 04/07/2024

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Chief Complaint

• Headache and dizziness

History of Present Illness

Mr. Doe is a 54-year-old male presenting with a three-week history of persistent headache, primarily located in the frontal region, rated 7/10 in severity. He also reports occasional dizziness, especially when standing up quickly. He denies any recent head trauma, visual changes, or focal weakness.

Past Medical History

• Hypertension
• Migraine headaches

Medications

• Lisinopril for hypertension
• Over-the-counter ibuprofen for headaches as needed

Allergies

• None known

Social History

• Non-smoker
• Occasional alcohol use

Family History

• Mother had a history of migraines

Review of Systems

• Negative for numbness, tingling, or weakness in extremities
• Negative for changes in speech or coordination
• Positive for light sensitivity and sound sensitivity during headaches

Physical Examination

• General: Alert and oriented, no acute distress
• Neurological: Cranial nerves intact, no focal deficits, normal gait
• Cardiovascular: Regular rate and rhythm, no murmurs

Assessment and Plan

1. Chronic migraine headaches: Adjust current migraine management plan by adding a preventive medication (topiramate) and optimizing acute treatment (sumatriptan) as needed. Emphasize lifestyle modifications and stress management techniques.
2. Hypertension: Continue lisinopril for blood pressure control. Advise on dietary changes and regular exercise.
3. Follow-up: Schedule a follow-up appointment in six weeks to assess response to new migraine management plan and blood pressure control.

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Electronically signed by [Provider's Name], MD. Date: 04/07/2024. Time: 10:45.