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Medwriter AI Session
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Live TranscriptionSession: 05:32
Dr: Good morning. Tell me about the headaches you've been experiencing.
Patient: They've become more frequent, almost daily now. Usually a throbbing pain behind my left eye.
Dr: Any visual changes associated with them? Flashing lights or blind spots?
Patient: Sometimes I see wavy lines just before it starts. And light bothers me.
Dr: Okay. Let's check your cranial nerves. Can you follow my finger with just your eyes?
Patient: Okay... yes.
AI-Generated Note
Processing
📝SUBJECTIVE:
- Patient is a 45 y/o female presenting with increased frequency of headaches, now occurring almost daily for the past month.
- Describes pain as left-sided, retro-orbital, throbbing, rated 7/10 severity.
- Reports associated photophobia and occasional visual aura (scintillating scotoma - "wavy lines") preceding headache onset.
- No reported nausea, vomiting, or focal neurological deficits.
- Denies recent head trauma.
🧠NEUROLOGICAL EXAM:
- Mental Status: Alert and oriented x4, appropriate mood and affect.
- Cranial Nerves: II-XII grossly intact. PERRLA. EOM intact without nystagmus. Funduscopic exam deferred.
- Motor: Strength 5/5 throughout all extremities. No pronator drift.
- Sensory: Intact to light touch, pinprick, vibration, and proprioception throughout.
- Reflexes: 2+ and symmetric throughout.
- Coordination: Finger-to-nose and heel-to-shin intact bilaterally. No dysmetria.
- Gait: Normal base, stride, and arm swing. Tandem gait stable.
📋ASSESSMENT:
- Migraine with aura (G43.109): Likely diagnosis given headache characteristics, photophobia, and visual aura.
- Rule out secondary causes of headache.
📝PLAN:
- Prescribe Sumatriptan 50mg PO PRN at headache onset, max 2 doses/24h.
- Recommend headache diary to track frequency, triggers, and medication use.
- Counsel on lifestyle modifications (trigger avoidance, regular sleep).
- Consider MRI Brain w/o contrast if no improvement or worsening symptoms.
- RTC in 6 weeks for follow-up.
- 99204 - E/M code appropriate for new patient visit complexity.
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