Outpatient visit · 14:30Draft ready
Reason for the visit
Headache for about two weeks, mostly on waking. 00:18
History of present illness
Band-like frontal pain, intensity 6 out of 10, worse during periods of work stress. Denies nausea, vomiting, and visual disturbances. 00:41
Past medical history
Hypertension for about five years. 01:52
Current medication
Ramipril 5 mg in the morning. 02:05
Examination
BP 150/95 mmHg, HR 76 bpm. Normal neurological examination. 03:30
Assessment
Probable tension-type headache in a hypertensive patient with blood pressure above target. dictated
Plan
Full blood count, renal function, and electrolytes. Headache diary and home blood pressure readings. Follow-up in one month. dictated
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