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Teleconsult Call Summary

A 23-year-old female presented with a one day history of throbbing right-sided headache. She reported no other symptoms like nausea, vomiting, or vision changes. Her headache resolved with rest. The teleconsult doctor diagnosed her with migraine and advised her to monitor for recurrence or worsening of symptoms, avoid strenuous activity, and increase fluid intake. As she was not physically examined, further consultation was recommended if symptoms persisted or changed.

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Jhade Ann Cayanes
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1K views2 pages

Teleconsult Call Summary

A 23-year-old female presented with a one day history of throbbing right-sided headache. She reported no other symptoms like nausea, vomiting, or vision changes. Her headache resolved with rest. The teleconsult doctor diagnosed her with migraine and advised her to monitor for recurrence or worsening of symptoms, avoid strenuous activity, and increase fluid intake. As she was not physically examined, further consultation was recommended if symptoms persisted or changed.

Uploaded by

Jhade Ann Cayanes
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Teleconsult Call Summary

Disclaimer:
This teleconsult summary is limited and is solely based on the facts that you have narrated and our
appreciation of the same. The summary may vary when the facts are changed or further
elaborated. ​This document is not meant to serve as a medical certificate. Patients are
advised to go see and consult with a doctor should symptoms persist.

MAXICARE CARD NO : 1168 0110 7794 4745

PATIENT NAME : CAYANES, JHADE ANN P.

COMPANY : GENPACT SERVICES LLC

BIRTHDATE : 02/18/1997

AGE & GENDER : 23 / F

CONTACT NUMBER : 09175280486

EMAIL ADDRESS : jacayanes@gmail.com

ATTENDING TELECONSULT DOCTOR : ANDE ENRIQUE B. VALENCIA, MD

DATE AND TIME OF TELECONSULT : 08/18/2020 @

CHIEF COMPLAINT : Headache

Patient is a 23 year old female consulting due to headache.


History started 1 day prior when patient reported onset of a
throbbing right-sided unilateral headache. This was not
associated with any nausea, vomiting, blurring of vision, fever,
weakness, or numbness. Patient reported to have rested and
noted relief of symptoms. Currently, no recurrence of headache

IMPRESSION : Migraine

Form Template Control: Contact Center/May 9, 2019/FO-CC-0.058/Rev.01


Teleconsult Call Summary
ADVICE GIVEN : RECOMMENDATIONS

1. Advised to monitor symptoms and watch out for


recurrence and worsening of headache, weakness,
numbness, vomiting, slurring of speech which would
require further consult
2. Advised to avoid strenuous physical activities
3. Advised to increase oral fluid intake

PATIENT NOT PHYSICALLY SEEN NOR EXAMINED. ​If the patient


is for medical clearance or fit to work status, he/she should be
seen or examined by a physician at a Maxicare-affiliated
clinic/hospital.

Well advised.
--------------------------Nothing follows----------------------------------

Form Template Control: Contact Center/May 9, 2019/FO-CC-0.058/Rev.01

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