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S: Subjective
The patient reports feeling fatigued for the past week, with intermittent headaches. Denies dizziness, nausea, or vision changes.
O: Objective
Vital signs: BP 120/80, HR 72, RR 16, Temp 98.6°F
Physical exam: No abnormalities noted on examination. Mild tenderness in the temporal region.
A: Assessment
Likely tension-type headaches. Fatigue could be related to stress or insufficient sleep.
P: Plan
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Recommend rest, hydration, and stress management techniques.
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Prescribe over-the-counter pain relievers (ibuprofen 200 mg as needed).
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Follow-up in 1 week or sooner if symptoms worsen.
