Name: M
Age: 25

Chief complaint:
Persistent headache that does not wear off with medication. Took Paracetamol and Diclofenace Sodium on 25/07/2009. Associated with slight blurring of vision and laboured breathing.

History of present illness:
Headache started after getting back from work at 7 am, 25/07/09. Was only able to get 2 hours of sleep, had to wake up to rush to meet caterer to get test food. Rushed to a friend’s wedding right after. Was feeling dizzy by then. Had another 2 hours of sleep but headache did not resolve. Had to do another night shift on the same day. Headache worsened as an unusually huge number of patients flocked the Emergency Department. No lost of appetite, nausea or vomiting.

Acute deprivation of sleep. Hahaha.

Pharmaceutical (and non-pharmaceutical) management:
Cadbury Bytes 80 g STAT
Yahoo Messenger chat with Mr Sunshine STAT
Tramadol 1 cap STAT then PRN. Suka hati je kan.
Gutt. Hypromellose 2 drops PRN BE
To get at least 8 7 6 hours of sleep after work. But I have another wedding to attend later !

To consult doctor if symptoms persist.


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