Diagnosed Lower Back Pain

The patient reported lower back stiffness, aching pain, and limited mobility especially in the mornings.
A physical exam revealed lumbar tenderness and reduced flexion.

A diagnosis of mechanical lower back pain was made, likely due to posture, strain, or muscle imbalance. Recommended treatments included stretching exercises, physical therapy, and temporary avoidance of heavy lifting.

Medication options discussed were Ibuprofen or Paracetamol for short-term pain management.

Diagnosed Bladder Infection

The patient reported frequent urination, burning sensation while urinating, and lower abdominal discomfort.
A urine sample showed presence of leukocytes and positive nitrites, indicating bacterial infection.

A diagnosis of bladder infection (cystitis) was made. It was considered uncomplicated and likely caused by E. coli.
Treatment included increased fluid intake and temporary avoidance of caffeine or irritants.

Prescribed antibiotics included Nitrofurantoin or Trimethoprim-sulfamethoxazole.

Diagnosed Hypertension

The patient reported headaches, dizziness, and blurred vision.
Blood pressure was measured at 152/95 mmHg.

A diagnosis of stage 1 hypertension was made, with contributing factors including poor diet, inactivity, and family history. Lifestyle changes such as reduced sodium intake and regular exercise were advised.

Medication options discussed included Lisinopril, Amlodipine, or Hydrochlorothiazide.

Diagnosed Chronic Headache

The patient reported persistent headaches occurring on most days over the past three months, accompanied by nausea, light sensitivity, and fatigue.
Neurological examination and MRI scan showed no acute abnormalities.

A diagnosis of chronic headache was made, likely due to stress and sleep disturbances.
Recommended interventions included sleep hygiene, stress management, and cognitive behavioral therapy (CBT).

Medications discussed included Amitriptyline, Topiramate, or Propranolol.

Diagnosed Left Lower Leg Pain

The patient reported pain in the left lower leg after prolonged walking, described as dull and throbbing. Additional symptoms included swelling and tenderness to touch.
A physical exam and X-ray ruled out fractures.

A diagnosis of musculoskeletal pain was made, likely due to overuse or strain.
Conservative management was advised including rest, ice application, and elevation.

Pain control discussed with Ibuprofen and Acetaminophen.

Vaccination AZD1/2RX_COD AstraZeneca (1/2)

The patient received a COVID-19 vaccine (AZD1/2RX_COD AstraZeneca) as part of the routine immunization schedule.
Pre-vaccination screening showed no contraindications.

Follow-up dosis scheduled for: September 9, 2021.