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Chamara Silva

Patient ID: PAT005
Age: 29
Gender: Male
Blood Group: O-
Phone: +94771234575

1

Clinical Notes

0

Prescriptions

0

Lab Orders

2

Radiology Orders

Recent Vital Signs

Recorded: 22 Sep 2025 01:12
Temp: 36.9°C
BP: 125/80
HR: 82 bpm
SpO2: 98%
Weight: 70.00 kg
BMI: 22.86

Clinical Notes

Consultation Note

by Dr. Dr. Lisa Anderson • 22 Sep 2025 01:12

Consultation
DIAGNOSIS:

Migraine without aura

SUBJECTIVE:

Severe throbbing headache for 2 days, mainly left temporal area. Photophobia and nausea present. Similar to previous episodes.

OBJECTIVE:

Patient appears distressed. Neurological examination normal. No focal deficits. Neck supple.

ASSESSMENT:

Migraine headache, consistent with patient history. No red flag symptoms.

PLAN:

Sumatriptan 50mg stat. Rest in dark room. Follow-up if not resolved in 24 hours.

Prescriptions

No prescriptions found

Medical History

No medical history found

Allergies & Alerts

No known allergies

Lab Orders

No lab orders

Radiology Orders

RAD003

Dr. Dr. Lisa Anderson • 24 Sep 2025

Ordered
CT Scan - Head
Severe headache investigation
RAD004003

Dr. Dr. Lisa Anderson • 22 Sep 2025

Ordered
CT Scan - Head
Severe headache, rule out secondary causes

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