Routine Consultation Template

1. The patient reports having persistent headaches for the last two weeks. The headaches are described as throbbing and moderate in intensity, often accompanied by nausea and light sensitivity. The patient has been using paracetamol with minimal relief.
Plan:
1. Advise the patient to keep a headache diary to identify possible triggers.
2. Prescribe sumatriptan for acute headache relief.
3. Schedule a follow-up appointment in two weeks to evaluate the treatment's effectiveness.
2. The patient complains of lower back pain that has lasted for three months. The pain is dull and constant, with occasional sharp exacerbations. It is worsened by prolonged sitting and relieved by rest. The patient has been using ibuprofen with partial relief.
Plan:
1. Recommend physiotherapy sessions to improve posture and strengthen back muscles.
2. Continue ibuprofen as needed for pain management.
3. Consider imaging studies if no improvement is observed in four weeks.
3. The patient has been experiencing intermittent episodes of palpitations for the past month. The palpitations are described as a rapid heartbeat lasting a few minutes, often occurring at rest. No associated chest pain or shortness of breath is reported. The patient is not on any current treatment for this issue.
Plan:
1. Order an electrocardiogram to assess cardiac rhythm.
2. Advise the patient to avoid caffeine and other stimulants.
3. Schedule a cardiology referral if palpitations continue.
4. The patient reports a persistent cough for the last ten days. The cough is dry and non-productive, with no associated fever or shortness of breath. The patient has been using over-the-counter cough syrup with little effect.
Plan:
1. Prescribe a short course of inhaled corticosteroids to reduce airway inflammation.
2. Encourage increased fluid intake to help soothe the throat.
3. Reassess in one week if symptoms persist.
PMHx: The patient has a history of hypertension, managed with lisinopril. No known medication side effects.
Social and Family history: The patient is a non-smoker and consumes alcohol occasionally. Family history is significant for hypertension in the father.
Examination: Blood pressure is 130/85 mmHg, heart rate is 78 beats per minute, and respiratory rate is 16 breaths per minute. No abnormalities detected on cardiovascular and respiratory examination.
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