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| Patient name: James | |
| Last visit: 21/04/2023 at 16:00. | |
| Subjective: James is a 28-year-old male who presents with a chief complaint of migraines. He reports that he has been having migraines for the past two to three months, and they usually start around 9am and get worse until noon. He states that the migraines are worse when he has a sugary breakfast or drinks a lot of soda. He also reports that the migraines can affect his vision, causing sparkles that occlude his vision. | |
| Objective: James is an alert and oriented male in no acute distress. His vital signs are within normal limits. He has no physical signs of distress. | |
| Assessment: Migraines | |
| Plan: Prescribe ibuprofen to be taken daily. If symptoms persist, return in two weeks for sumatriptan. | |
| Subjective: James is a 28-year-old male who presents with a chief complaint of migraines. He reports that he has been having migraines for the past two to three months, and they usually start around 9am and get worse until noon. He states that the migraines are worse when he has a sugary breakfast or drinks a lot of soda. He also reports that the migraines can affect his vision, causing sparkles that occlude his vision. | |
| Objective: James is an alert and oriented male in no acute distress. His vital signs are within normal limits. He has no physical signs of distress. | |
| Assessment: Migraines | |
| Plan: Prescribe ibuprofen to be taken daily. If symptoms persist, return in two weeks for sumatriptan. | |
| Subjective: James is a 28-year-old male who presents with a chief complaint of migraines. He reports that he has been having migraines for the past two to three months, and they usually start around 9am and get worse until noon. He states that the migraines are worse when he has a sugary breakfast or drinks a lot of soda. He also reports that the migraines can affect his vision, causing sparkles that occlude his vision. | |
| Objective: James is an alert and oriented male in no acute distress. His vital signs are within normal limits. He has no physical signs of distress. | |
| Assessment: Migraines | |
| Plan: Prescribe ibuprofen to be taken daily. If symptoms persist, return in two weeks for sumatriptan. | |