Sample Follow Up Note

DATE               AIM F/U Visit

33 y.o. F healthy

1. Migraine Headache

Returns to clinic for refill of medication. Reports feeling great, had good response to triptan. She has only had 4-5 episodes since her last visit 6 months ago. She is trying to avoid wine, and bad perfumes.  Headaches usually respond quickly to medication, she only needs to take one tablet/attack, she has tried to spare the use of triptans given the high cost.   There is no chest pain, tightness, or SOB associated with these medications.  She has had good response also from OTC pain medications.  Otherwise, she has no complaints.  Work is going well, she was recently promoted.  No significant family or job stress.

ROS: no recent cough, URI, weight is slightly up 5 lbs from before. She is still active with good exercise tolerance, however she is eating more and exercising less.

Meds: rizatriptan 10mg prn x1, multivitamin                         Allergy: NKDA

Exam: Well appearing, walked briskly into room.

 BP 110/70 R 14 P 72 afebrile BMI 23

HEENT: disc nl, EOMI, PERRL

Neck: no thyromegaly

Cor: RRR S1, S2 no murmur

Lungs: clear

Abdomen: benign, soft

Extrem: no edema

Neuro: grossly non focal

Labs: cholersterol 185/100/50/105 Hct nl, nl MCV   Pap this year-wnl

Impression: 32 y.o. with migraine without aura, responding well to prn rizatriptan.

1. Migraine: refill meds, advised to trial simple OTC analgesics ( like excedrin migraine)

given the high cost of triptans. Continue to avoid triggers as she is doing.

2. Advice increase exercise at least 3 times a week for 20 minutes, and increase vegetable and fruit intake, 5 servings/day.

3. HM: Td booster last year, to have pap in 6 months, counseling provided on safety/seat belt use.

4. RTC 1 yr or prn.

HM td 05, pap 05