Clinical note · #2
Office & outpatient
Patient: Michael Adams · DOB: 04/25/1985 · Date of visit: 09/12/2023
Chief complaint: Mild headache
History: The patient is a 38-year-old male who presents with a mild headache that started yesterday afternoon. Describes it as a dull, non-throbbing pain located in the forehead region. No visual disturbances, nausea, or vomiting. Denies recent trauma, fever, or neck stiffness.
Physical examination: General: patient is alert and oriented. Neurological: cranial nerves II–XII are intact. No focal neurological deficits. Musculoskeletal: no neck stiffness or tenderness.
Assessment and plan: Tension headache. Recommended rest, hydration, and over-the-counter pain relief (ibuprofen) as needed. Follow up if headache worsens or persists beyond a few days.
Electronically signed by Tera, John, NP 09/12/2023, 17:00