week 8 soap note

STUDENT NAME:

DATE OF ASSIGNMENT: 06/19/2020

Patient Initials: P. F

Date of Encounter: 06/19/2020

Sex: Female

Age/DOB/Place of Birth: 16 y/o, DOB: 05/01/2004, Miami, FL

SUBJECTIVE

Historian: Patient P.F

Present Concerns/CC: “I have horrible headaches, and the light bothers me”

Reason given by the patient for seeking medical care “in quotes”

Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care;

Sports/physical activity; Developmental Hx)

Patient is sexually inactive, she is in high school, and will start her sophomore year in the fall. She spends most of her time painting and aspires to be an artist in the future. She also plays some video games with her friends and calls them from time to time. She doesn’t practice sports, and doesn’t exercise either.

HPI: (must include all components - OLD CARTS)

The patient came today with her older brother. She states that over the past two months, she has been having very strong headaches (7/10) and has an insensitivity to light when she has the headaches. The pain is located on both sides of her head, and the patient states that the pain is pulsatile, and they last for 3 days, it changes its intensity when she changes positions. She also experiences some visual disturbances, and sees some shapes when having the headache. The headaches started 2 months ago, and she states that she has had around 4 since then. Nothing seems to alleviate them including Tylenol.

Medications: (List with reason for meds)

Tylenol 325mg, 3 times per day (Headaches)

PMH:

Allergies: None

Medication Intolerances:

None

Chronic Illnesses/Major traumas:

None

Hospitalizations/Surgeries:

None

Immunizations: All vaccines up to date with the exception of the most recent influenza vaccine.

Family History (please identify all immediate family)

Mother: 40 years old, overweight.

Father: 41 years old, no current health problems.

1 older brother (19 years old).

Social History (Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status)

Will start her second year of high school soon. Does not work. Lives with her mom, dad, and brother in an apartment in Miami, FL. Single, does not use drugs, or drink alcohol. Does not use electronic cigarettes. Feels safe at home and in school.

Review of Systems (ROS)

General

Positive for headaches, denies nausea, denies fever, denies chills.

Cardiovascular

Denies chest pain, pressure, palpitations.

Skin

Denies skin lesions, itching, or redness.

Respiratory

Denies shortness of breath, denies cough, denies difficulty breathing.

Eyes

Positive for some visual disturbances when having a headache, positive for insensitivity to light. Denies blurriness, denies double vision.

Gastrointestinal

Denies nausea or abdominal pain. Denies diarrhea. Denies vomiting.

Ears

Denies hearing loss, pain, or drainage.

Genitourinary/Gynecological

Age of menarche: 12 y/o, LMP: Around the last week of May, normal flow.

Denies painful urination, denies increased frequency.

Nose/Mouth/Throat

Denies throat pain. Denies difficulty swallowing, denies congestion, denies discharge, denies mouth pain.

Musculoskeletal

Denies pain, denies limited range of movement.

Breast

Denies tenderness, lumps, or any masses

Neurological

Positive for headaches. Denies numbing or loss of sensation, denies dizziness, denies syncope, paralysis, or ataxia

Heme/Lymph/Endo

Denies anemia, bleeding or bruising, denies enlarged nodes. Denies change in temperature sensitivity.

Psychiatric

Denies anxiety, or depression. Denies mood swings, denies insomnia.

OBJECTIVE (plot height/weight/head circumference along with noting percentiles)

Attach growth chart

Weight 120 lbs.

Around 55th percentile

Temp 98.3 F

BP 110/65

Height 63 inches, 5’3”

Around 35th percentile

BMI: 21.3

Growth chart at bottom of SOAP Note

Pulse 68 bpm

Resp 17/min

OBJECTIVE (Physical Examination)

General Appearance and parent-child interaction

Patient looks well groomed, and in no obvious distress. She came with her brother today and their interaction seems normal, there are no signs of abuse or fear.

Skin

Skin around the nose, eyes, and mouth is normal for age. No presence of comedones, or papulopustules. No cyanosis, clubbing or bruises.

HEENT

Head is normocephalic, atraumatic. Eyes: PERRLA, no conjunctival or scleral infection, no conjunctival injection, fundus: no papilledema. Ears: bilateral TM’s pearly grey with positive light reflex. Neck: supple, full ROM, no rigidity. Mouth/Throat: Throat is visibly pink, and non-inflammatory. Oral mucosa pink and moist, gag reflex present. Frontal and maxillary sinus palpated, without tenderness. Temporomandibular joints: no tenderness, full range of motion; visual acuity 20/20.

Cardiovascular

S1, S2 heard, normal rate, normal rhythm, 2 sec capillary refills, no murmurs, no gallops, no palpation, and no edema.

Respiratory

Lungs clear to auscultation bilaterally anteriorly and posteriorly, normal respiratory effort. No rales, no Ronchi, No wheezing.

Gastrointestinal

Soft to palpation. All 4 quadrants palpated, no masses. Bowel sounds present in all four quadrants. No ascites, no splenomegaly, no hepatomegaly. No rebound, no guarding. No visible signs of dehydration.

Breast

Deferred

Genitourinary

No CVA tenderness. External genitalia assessment deferred.

Musculoskeletal

Normal gait and ROM. No rigidity, no deformities. No atrophy

Neurological

Normal tone, no local findings. Non hemiparetic neurologic deficit. Romberg negative.

Psychiatric

No depression or anxiety, no insomnia.

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

None

Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale For adolescents (HEADSSSVG Assessment)

Tanner Stage 4. When the patient is asked, she states that she has some pubic hair, but not fully distributed. Also a great majority of girls reach menarche at this age, and the patient has reached menarche. (Emmanuel & Bokor, 2019).

HEADSS Assessment (Katzenllenbogen, n.d.)

H- Lives with her parents and brother in an apartment in Miami, FL. Have lived in this apartment for the past 2 years. Patient feels safe at home.

E- Currently in summer vacation. Will begin second year of high school in the Fall.

A- Paints and draws most of her days. Near the evening plays video games with her friends and/or talks to them over FaceTime.

D- Patients states that she has never been in contact with or ever experienced being around anyone with drugs of any kind.

S- Patient is sexually inactive and has never had a boyfriend.

S- Patient states that she has never felt suicidal thoughts or tendencies.

ASSESSMENT (Diagnosis – 3 Differentials and Primary)

· Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials)

· Document Evidence based Rationale for ROS and each differential with pertinent positives and negatives

· Primary diagnosis

· Is #1 on list of differentials

· Evidence for primary diagnosis should be supported in the Subjective and Objective exams.

1) Migraine (G43) Patient is most likely in the attack phase of migraines with some symptoms of the aura phase. She has quick-onset headaches affecting both sides of her head that cause great pain. She is also experiencing light insensitivity which is a common characteristic of migraine headaches (Greene, Irwin, & Gelfand, 2019).

2) Episodic cluster headache, non-intractable (G44.019) Cluster headaches share many similar symptoms with migraines, but differ in the areas they cause pain in. For this reason, cluster headache is a less likely diagnosis but should still be considered (Cluster headaches, 2019)

3) Headache (R51) Headaches can be provoked by many things including, food, stress, and sleep patterns. It is common for all age groups to experience headaches. This is also less likely to the chronic nature of her headaches as well as their characteristics (Headache: When to worry, what to do, 2019)

PLAN including education

PLAN including education

· Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature.

· Include EB rationale for all aspects of your treatment plan:

· Vaccines administered this visit

· Vaccine administration forms given

· Medication-amounts and mg/kg for medications

· Laboratory tests ordered

· Diagnostic tests ordered

· Patient education including preventive care and anticipatory guidance 9 Non-medication treatments Follow-up appointment with detailed plan of f/u

Treatment:

The first line treatment of migraines are NSAID’s such ibuprofen (Greene, Irwin, & Gelfand, 2019). Since the patient states that she has taken Tylenol to no effect, I would like to start her on Ibuprofen 400 mg every 4 to 6 hours for pain. As compared to acetaminophen, ibuprofen was found to be more effective at reducing symptoms for the first 2 hours after a migraine attack (Greene, Irwin, & Gelfand, 2019). I would like to try an NSAID first before tying a Triptan drug. Triptan should be referred to patient that have an inadequate response to NSAID’s such as ibuprofen. Apart from this treatment, there are some non-pharmacological treatments that may help her during a migraine attack. Stay in a dark, cool room, that is quiet and prioritize hydration and sleep. Pain medication should be taken as early as possible in the onset in order to have the maximum effect. (Migraine, 2020). There also exist some preventative forms of medication that can help lessen or eliminate migraine and their associate symptoms. I would hold back on prescribing any experimental treatments until we are certain that the patient has chronic, recurring migraines that do not alleviate with pain medication. Please return to the clinic in 2 weeks to follow up on the treatment and to re-evaluate.

References

Cluster headache. (2019, June 04). Retrieved June 19, 2020, from https://www.mayoclinic.org/diseases-conditions/cluster-headache/symptoms-causes/syc-20352080

Emmanuel, M., & Bokor, B. R. (2019, May 13). Tanner Stages. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK470280/

Greene, K., Irwin, S. L., & Gelfand, A. A. (2019). Pediatric Migraine. Neurologic Clinics, 37(4), 815-833.

Headache: When to worry, what to do. (2019, February 5). Retrieved June 19, 2020, from https://www.health.harvard.edu/pain/headache-when-to-worry-what-to-do

Katzenellenbogen, R. (n.d.). HEADSS: The "Review of Systems" for Adolescents. Retrieved May 3, 2020, from https://journalofethics.ama-assn.org/article/headss-review-systems-adolescents/2005-03

Migraine. (2020, January 16). Retrieved June 19, 2020, from https://www.mayoclinic.org/diseases-conditions/migraine-headache/symptoms-causes/syc-20360201