DIALOGUE

[doctor] carolyn is a 34 -year-old female with a history of diabetes mellitus type two who is here today with a headache so hi there carolyn it's nice to see you again listen i'm sorry you're having headaches well let's talk about it but i would like to record this conversation with this app that's gon na help me focus on you more would that be okay with you
[patient] yes that's okay
[doctor] okay great thanks so carolyn tell me about your headache and headache or headaches when did when did they start and and what symptoms are you having
[patient] my headache started about a week ago it's feeling like a dull pain in the back of my head i have flushing in my ears they get really red and hot and sometimes i just feel a little bit dizzy when i get these headaches but i've taken tylenol and advil and it's not really going away it just keeps coming back
[doctor] okay and alright and so this started about a week ago has it been fairly constant since it started or does it come and go does it come and go or what
[patient] it comes and goes i it it's relieved when i take my tylenol or advil but then it comes right back
[doctor] hmmm okay and do you notice any any timing difference you know is it is it worse in the morning worse in the evening is there anything else that makes it better or worse
[patient] it's definitely worse in the evening
[doctor] okay and do you feel any sort of tightness in the back of your neck or in your shoulders or you know you said it's in the back of your head primarily any discomfort anywhere else
[patient] yes no just in the back of my head
[doctor] okay and did the headache start all of a sudden carolyn or has it been gradual or what
[patient] i've been under a lot of stress lately so maybe about when some stress started occurring
[doctor] okay okay and alright and have you noticed any fever along with the headache
[patient] no no fever
[doctor] okay and any visual changes you know wavy lines in your vision spots in your vision or anything like that
[patient] no
[doctor] okay and have you had headaches like this before
[patient] i have
[doctor] okay so this is n't the worst headache you've ever had what did you say
[patient] no it's not
[doctor] okay alright and so okay fair enough now how's your diabetes been been been doing lately have you what have your blood sugars been running in the low one hundreds or two hundreds or what
[patient] i have n't been checking my blood sugars
[doctor] really okay well we will get you back on that and and we can talk about that but how about your metformin are you still taking the five hundred milligrams once a day no actually it looks like we increased your metformin to five hundred milligrams twice a day last visit are you still taking that
[patient] yes
[doctor] okay great and okay you're still watching your diet and getting some exercise
[patient] i have not been eating well because i've been stressed over the last week but i have n't been exercising for maybe the past week but generally i've been doing better
[doctor] okay the headache has has maybe made you feel uncomfortable and prevented your your exercise would you say or what
[patient] yes it has
[doctor] okay okay so you probably have n't been out golfing i remember you're a big golfer so not not lately uh so you know being
[patient] not lately
[doctor] being down being down here in florida we got ta get get some golf in so hey did you see the masters by the way a few weeks ago was n't that i do n't know did you happen to catch it
[patient] i did
[doctor] yeah that was crazy what a what a finish what an amazing what an amazing tournament right what do you think yeah yeah that's great well we'll we'll get you feeling better and get you back out there and now are you still working a lot on the computer ac or
[patient] i am
[doctor] carolyn okay yeah you're still working a lot on the computer for work okay are you taking breaks every hour or so you know get up stand around walk stand walk around that can be helpful
[patient] no i really do n't get the opportunity to
[doctor] hmmm okay understood alright well listen let's go ahead and examine you okay so so on your physical exam your physical exam is pretty normal unremarkable for the most part and you know few things a few exceptions so first of all on your heent exam your eye exam your extraocular motions are intact without pain you have a funduscopic exam that shows no papilledema that's good that just means there's no swelling in the back of your eye and on your neck exam you do have some posterior mild posterior paraspinal muscular tenderness in the cervical spine and in bilateral trapezius musculature as well and some tightness in those muscles as well and otherwise on your exam let's see your heart exam on your heart exam you have that grade three out of six systolic ejection murmur that's unchanged from your prior exam so it just means i hear some sounds in your heart as it's beating and i'm not too worried about that we'll watch that and otherwise normal heart exam and and your physical examination otherwise is normal and unremarkable and so now let's talk about my assessment and your plan so carolyn for your first problem of the headache i do think that you have a tension type headache and i think this because you've got some tension and tightness in your paraspinal muscles meaning the muscles around your neck and your shoulders and you know working at the computer i think is contributing to this and also probably the stress so you can continue to take that tylenol for the pain i'm also gon na give you a mild muscle relaxant i'll write you for flexeril five milligrams three times a day and you can take that that will help relax those muscles in your neck and that should help with the symptoms i want you to come back or give us a call if the headaches become more severe or suddenly worsen or you develop a fever but i do n't think that this is a a sign of a stroke or any bleeding in your brain or anything like that i think it's more related to tightness in your muscles in your neck now for your second problem of your diabetes mellitus let's continue you on the metformin five hundred milligrams i am going to order a hemoglobin a1c and also a cbc and a chem-12 to check some of your blood tests blood chemistries and so forth and we will continue you on the metformin i do want you to check your blood sugars daily and that will be very helpful so when you come back in a month i want you to bring those numbers with you we can talk about it again and please do try to get back into your exercise routine that's really gon na help you keep those blood sugars under control as well okay so how does that sound for a plan any other questions for me
[patient] well would it so only call if if it gets worse or not any better
[doctor] yeah that that just right but also let's set up an appointment in four weeks and i wan na see you back in four weeks if it's not if the headache is not better within the next few days with this flexeril then you can give us a call and and get back in later this week or early next but definitely if things get worse give us a call sooner and you know i meant to ask you on i wanted to ask if you had a history of any any trauma meaning have you hit your head or you have n't fallen hit your head or anything like that have you
[patient] no no i think it's just stress
[doctor] okay alright understood okay great well then i'll see you back in a month if not before okay you take care of yourself nice seeing you
[patient] thank you
[doctor] sure

CLINICAL NOTE

CHIEF COMPLAINT

Headache.

MEDICAL HISTORY

Patient reports history of diabetes mellitus type 2.

SOCIAL HISTORY

Patient reports she enjoys golfing.

MEDICATIONS

Patient reports taking metformin 500 mg twice a day.

REVIEW OF SYSTEMS

Constitutional: Denies fever.
Eyes: Denies vision changes.
HENT: Reports ear flushing.
Neurological: Reports headaches and dizziness.

PHYSICAL EXAM

Eyes
- Examination: No papilledema.
- Extraocular Muscles: Grossly Intact without pain.

Neck
- General Examination: Mild posterior paraspinal muscular tenderness in the cervical spine and bilateral trapezius musculature as well tightness.

Cardiovascular
- Auscultation of Heart: Grade 3 out of 6 systolic ejection murmur that is unchanged from prior exam.

ASSESSMENT AND PLAN

1. Headache.
- Medical Reasoning: Patient presents with symptoms similar to a tension headache. On exam she has tension and tightness in her paraspinal muscles as well likely due to working at the computer. Additionally, I think her stress level is also a contributing factor.
- Patient Education and Counseling: I discussed the diagnosis with the patient today. I explained that her headaches may be caused by tension around the muscles around her neck and shoulders. I advised her that her symptoms do not appear related to signs of a stroke or brain bleeding. Questions were asked and answered today.
- Medical Treatment: She can continue to take Tylenol for the pain. Prescription for Flexeril 5 mg 3 times a day is provided as well.

2. Diabetes mellitus.
- Medical Reasoning: Due to her headaches, she has been inconsistent with her exercise and checking her blood sugar.
- Patient Education and Counseling: We discussed the importance of maintaining a healthy lifestyle. We also discussed the importance of keeping a watchful eye on her blood sugar levels.
- Medical Treatment: She will continue taking metformin 500 mg daily. Order for hemoglobin A1c, CBC, and CMP provided today. She will check her blood sugar daily and will bring that information in on her next visit.

Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

INSTRUCTIONS

The patient will follow up in 1 month. She can follow up or call sooner if her headaches become more severe or suddenly worsen or she develops a fever.