Patient is a 34-year-old female presenting with a 3-day history of progressive frontal headache, rated 7/10 in severity. Headache is throbbing in nature, worse in the morning, and partially relieved by ibuprofen. Associated symptoms include mild nausea and photophobia. No history of trauma, fever, or visual changes. Patient reports increased work-related stress over the past two weeks and poor sleep quality. She has a known history of Type 2 Diabetes and Hypertension, both currently managed with oral medications. Denies any chest pain, shortness of breath, or neurological symptoms.
Vitals: BP 152/94 mmHg (elevated), HR 88 bpm, Temp 36.8°C, SpO2 98% on room air, RR 16/min.
General: Alert and oriented, appears mildly uncomfortable, no acute distress.
HEENT: Pupils equal, round, reactive to light. No papilledema on fundoscopic exam. Mild tenderness over frontal sinuses bilaterally. Oropharynx clear.
Neuro: Cranial nerves II-XII intact. No focal neurological deficits. Normal gait and coordination. Deep tendon reflexes 2+ bilaterally.
CV: Regular rate and rhythm, no murmurs. No peripheral edema.
- Tension-type headache (G44.2) — likely stress-related, with migraine features to rule out
- Hypertension, poorly controlled (I10) — BP 152/94, above target despite current regimen
- Type 2 Diabetes Mellitus (E11.9) — stable on current management, due for HbA1c review
- Order CBC, BMP, and HbA1c for baseline labs
- Increase Losartan from 50mg to 100mg daily for blood pressure control
- Prescribe Sumatriptan 50mg PRN for acute headache episodes
- Recommend headache diary and stress management techniques
- Schedule follow-up in 2 weeks for BP recheck and lab review
- Refer to ophthalmology if headache persists or visual symptoms develop