You explain the headaches she describes
are consistent with muscle contraction, or "tension" headaches. Your
recommendations include keeping a headache journal and using acetaminophen
650mg every 4-6 hours PRN. You also encourage the patient to identify
additional areas of stress in her life, while trying to participate in
light exercise a few times a week to help reduce
You also suggest the patient talk with
school guidance counselor regarding her son's school behavior and academic
Lastly, you have Mrs. Miller schedule her
annual physical for next month, with plans to follow-up on her headaches and
stress level at that time.
A complete physical exam, including a
gynecological exam (clinical breast and pelvic exams and pap
smear). The patient should be educated on breast
Immunizations should be reviewed and
updated (tetanus and influenza). Due to the patient's hypothyroidism and use
of Synthroid, a TSH and T4 should be checked every six
Cholesterol levels within the desired
range (in this case <200mg/dL) do not need to be checked more frequently
than every three years.
Diet - A
low fat, high fiber diet, with at least 1200 mg/day of elemental calcium should
Exercise - You encourage Mrs. Miller to participate in a minimum of 20
minutes of aerobic exercise three times per week. You also discuss the
importance of strength building/resistance exercises to help maintain optimal
Substance Use- Mrs. Miller denies the use of tobacco products and
illicit drugs. She drinks one to two glasses of red wine each night to
help her "fall asleep".
Seat belt use is reviewed, as is the presence of smoke detectors in the home
and the use of helmets when bicycling.
Domestic violence - When Mrs. Miller is asked if she feels safe in her home,
her eyes quickly focus on the floor.
Mrs. Miller has many features suggestive
of domestic abuse: