Presenting Complaint

Frontal headache for three days
Low grade fever
Coryza with clear rhinorrhoea

History of Presenting Complaint

Patient reports headache localised to the front of the head for three days
Describes a sensation of pressure across the front of the face, worsening on bending forward
Pain severity rated 10 out of 10 on a numerical rating scale
No radiation of pain to other areas of the head or neck
Associated low grade fever
Associated nasal congestion with clear nasal discharge
No visual disturbance reported
No neck pain reported

Observations

Not discussed

On Examination

Not discussed

Plan

Not discussed

Safety Netting

Not discussed

Audit

Presenting Complaint

Frontal headache for three days [1]
Low grade fever [2]
Coryza with clear rhinorrhoea [3][4][5]

History of Presenting Complaint

Patient reports headache localised to the front of the head for three days [1][6]
Describes a sensation of pressure across the front of the face, worsening on bending forward [7]
Pain severity rated 10 out of 10 on a numerical rating scale [8]
No radiation of pain to other areas of the head or neck [9]
Associated low grade fever [2]
Associated nasal congestion with clear nasal discharge [3][4][5]
No visual disturbance reported [10]
No neck pain reported [10]

Observations

Not discussed

On Examination

Not discussed

Plan

Not discussed

Safety Netting

Not discussed

References

[1] [S2] 00:42 — Saya sakit kepala dah tiga Hari.

[2] [S2] 01:34 — Ada demam sikit ja.

[3] [S2] 01:39 — Ada selsema.

[4] [S2] 01:43 — Ada hingus.

[5] [S2] 01:46 — Hingus colour clear lah tak ada tak ada colour clear Biasa saja.

[6] [S1] 00:45 — Tiga Hari pakcik eh okey sakit kepala tu dekat. Mana makcik.

[7] [S2] 00:49 — Dekat belah depan kepala bila saya bila saya rokok bila saya. Bend forward. Rasa macam pressure. Dekat depan muka.

[8] [S2] 01:12 — Paling tinggi 10.

[9] [S1] 00:57 — Okey pakcik rasa pressure depan muka ada ah sakit di tempat lain KE Kat kepala tu dia pergi Kat mana mana bahagian kepala tak ada yang pakcik punya skala sakit tu satu sampai 10 10 paling tinggi berapa pakcik punya skala sakit pakcik sekarang.

[10] [S2] 01:29 — Tak ada tak ada langsung rasa tak ada langsung rasa APA.