SOAP NOTE

Name: P. L

Date: 03/09/2018

Sex: Male

Age/DOB/Place of Birth: 16 y.o/03/01/2001/Cuba

SUBJECTIVE

Historian: Mother and patient

Present Concerns/CC: “I’ve been having horrible headaches on and off for the last 2 weeks”

Child Profile:

Patient is a high school student with no significant past medical history. He is enrolled in a dual program where he is taking college classes in advance. Described by his mother as an A+ student. He does participate in sports at school being part of the baseball league. Patient goes to school during the day and spends most of his free time studying. He eats a balanced diet including meat, vegetables, and salads. Patient drinks water throughout the day and does not like soda beverages. Denies drinking energetic drinks. He uses seatbelt at all times while in a car.

HPI:

Otherwise healthy 16 y/o male seen in the office for complaints of daily headache for 2 weeks. Pain is described as dull and pounding and intermittent. Pain is mainly located in the back of the head but at times radiates to the top and to the sides. Patient can’t say if there are specific triggers for the pain because he experiences it at any time. Pain is alleviated by rest and in other instances he has taken Excedrin Extra Strength with little relief. Denies photophobia, blurred vision, or diplopia. Patient admits to some pressure with the studies as he is trying to get a full scholarship for university.

Med

Medications:

 He is not currently taking any medications. Has taken Excedrin Extra Strength 1 tab orally by mouth as needed for headache in the past.

PMHX:

Allergies: NKA

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: None

Immunizations: Up to date

Family History

Mother and father alive. Mother has history of GERD and father suffers from HTN. Paternal grandparents are deceased. Both of old age. Maternal grandfather and maternal grandmother are alive, and they only suffer from GERD and OA.

Social History

Patient is only child and lives with his parents. He is currently on high school. He is enrolled in a dual program where he is taking college classes in advance. He spends most of his time studying. He has applied to various universities and expects to obtain full scholarship. Mother denies guns at home or exposure to second hand smoking. Patient does not work because his school requires him to spend a great amount of time to it. Both parents are very supportive of patient. Patient denies being sexually active and denies having a girlfriend. He has a group of close friends.

ROS

General

Denies fever, weight loss or generalized weakness

Cardiovascular

Denies chest discomfort, palpitations, or chest pressure

Skin

Denies open wounds, rash, or hives

Respiratory

Denies for hemoptysis, tachypnea, dyspnea or cough

Eyes

Denies blurred vision, diplopia, and sense of curtain falling or intolerance of light. Positive for reading glasses.

Gastrointestinal

Denies nausea, vomiting, lack of appetite or changes in bowel habits

Ears

Denies ear pain, tinnitus, or discharge

Genitourinary/Gynecological

Denies changes in urine color, dysuria, or hematuria

Nose/Mouth/Throat

Denies mouth sores, epistaxis, nasal congestion, or difficulty swallowing

Musculoskeletal

Denies joint swelling, stiffness, or pain

Breast

Not examined

Neurological

Report headaches x 3 weeks. Negative for paralysis, tremors, seizures, speech difficulty or confusion

Heme/Lymph/Endo

Denies fatigue, anemia, cold/heat intolerance or enlarged lymph nodes

Psychiatric

Denies problems falling asleep or staying asleep, depression or suicidal ideations. Positive for high levels of stress and some anxiety

Weight 164 lbs

Temp 98.7

BP 122/63

Height 5’7”

Pulse 72

Resp: 18

General Appearance and parent‐child interaction:

Cooperative and calm patient accompanied by his mother. Both with clear and appropriate speech and language

Skin

Skin is intact. Good turgor. Capillary refill 2 seconds

HEENT

Head: Normocephalic, atraumatic. Eyes: symmetric. Normal eye lashes and lids, Clear conjunctiva. Visual fields full to confrontation. No ptosis. Pupils PERRLA. Ears: No trauma or drainage. Nontender tragus. Mouth: Intact gag reflex. Nose: Patent nares with midline septum. Neck: supple with no JVD and full ROM.

Cardiovascular

Normal heart rate and sounds. Pedal pulses 2+ bil. No cyanosis, clubbing or edema of the lower extremities

Respiratory

Lung fields clear to auscultation. Respiratory rate within normal parameter. Symmetric chest wall expansion. No use of accessory muscles observed.

Gastrointestinal

Abdomen is flat with normoactive bowel sounds in all quadrants. Exam negative for tenderness or guarding

Breast

Not examined during this visit

Genitourinary

No bladder distention or CVA tenderness

Musculoskeletal

Neurological

Extremities movable 5/5 strength. Intact coordination with finger to nose test. Intact sensation to light and deep touch. Reflexes 2 + throughout. Romberg test negative.

Psychiatric

Patient with adequate engagement in conversation, normal mood, no indications of depression at this time

In-house Lab Tests – document tests (results or pending)

MRI of the brain and cervical spine: Exam to be completed in an outpatient imaging

center as soon as possible

Diagnosis

Primary Diagnosis:

· Tension headache (G44.209): This diagnosis was selected based on physical examination and history of recent exposure to higher levels of stress. Pending MRI results to rule out other causes if any.

· Plan including education

· MRI scheduled for next day.

· Start Midrin 325 mg take 1 cap every 4 hours as needed for severe headache. Do not exceed 8 capsules per day.

· Motrin 800 mg 1 tablet every 8 hours as needed for pain

· Follow up in the office for tests results

Education

· Patient and mother educated about tension headaches and that they could be related to high stress levels. However, further testing was ordered to rule out other possible causes. Patient verbalized understanding and agreed to additional test to rule out more serious causes

Educated to keep a log with frequency of headaches

Instructed to take medications as prescribed and do not exceed recommended dosage.

Educated about the importance of a life –school balance, participate in physical activities, getting sufficient sleep and proper nutrition

Use relaxation and deep breathing techniques and take frequent brakes while using computer or other electronic devices (Donaldson, 2016)