Presenting Complaint

Headache for three days
Photophobia

History of Presenting Complaint

Not discussed

Observations

Temp 36.9

On Examination

Pupils equal and reactive

Plan

Paracetamol one gram four times a day

Safety Netting

Not discussed


Audit

Presenting Complaint

Headache for three days [1]
Photophobia [1]

History of Presenting Complaint

Not discussed

Observations

Temp 36.9 [1]

On Examination

Pupils equal and reactive [1]

Plan

Paracetamol one gram four times a day [1]

Safety Netting

Not discussed

References

[1] [S1] 00:01 — Headache for three days. Fever 36.9. Fotofobia. On examination, pupils equals and reactive. Plan is for paracetamol one gram, four times a day.