Primary Care Consultation Template

Clinician Specialty: Advanced Paramedic Verbal consent for use of Heidi AI scribe and option for opt out. A chaperone was offered and declined by the patient. Presenting Complaint: The patient presents with a sudden onset, severe headache radiating to the back of her head, accompanied by photophobia and neck stiffness. She rates the pain as 9/10. The symptoms started approximately 3 hours ago while she was at work. History: The headache began abruptly, described as a "thunderclap" headache. It has progressively worsened since onset. She denies any recent trauma or falls. No history of similar headaches. Past medical history includes controlled hypertension, diagnosed two years ago. Symptoms: The headache is described as throbbing and excruciating, located primarily in the occipital region but extending globally. She reports significant photophobia, needing to be in a dark room. Neck stiffness is present, making it difficult to flex her neck. Associated symptoms include nausea, but no vomiting. No focal neurological deficits reported or observed. Exclusion Of Red Flags: No history of recent head injury was reported. No visual changes, speech difficulties, or limb weakness were reported, excluding stroke-like symptoms. No fever or rash were reported, reducing suspicion of meningitis. Examination: Blood pressure 160/95 mmHg, Heart Rate 98 bpm, Respiratory Rate 18 breaths/min, Oxygen Saturation 98% on room air, Temperature 37.1°C. Patient appears distressed, holding her head, and is sensitive to light. Neurological examination reveals no focal motor or sensory deficits. Cranial nerves II-XII are intact. Neck stiffness is evident on passive flexion, indicative of meningism. No papilloedema noted on fundoscopy (simulated, as not always performed in pre-hospital setting). Social: The patient is a 45-year-old female, working as an office manager. She lives with her husband and two children. She denies smoking and consumes alcohol occasionally. No recent travel history. Her family provides a good support system. Plan: Administered 10mg of IV Metoclopramide for nausea and 1g IV Paracetamol for pain relief. Pain reassessment after 20 minutes showed slight improvement to 7/10. Immediate transfer to the nearest emergency department for urgent neurological assessment and imaging, given the thunderclap headache presentation. Educated the patient and her husband on the potential seriousness of the symptoms and the need for immediate hospital care. Advised to maintain a comfortable, quiet, and dark environment during transport.