SOAP note

Name: L. R

Pt. Encounter Number:

Date: 09/04/2020

Age: 28

Sex: Female

SUBJECTIVE

CC:

“I have horrible headaches”

HPI:

The patient came for an initial visit complaining of “horrible headaches”. The patient states that the headaches come and go, and usually last for about 6 hours each time. She has had around 4 headaches in the past month. The pain is described as a 6 out of 10 but can be much worse if the patient moves around too much or is in contact with a large amount of light. In these cases, the pain can be up 8 out of 10. The headaches began around 1 month ago when the patient started a big project with her company. The pain affects the patient’s whole head and is characterized as a throbbing or pounding pain.

Medications: (List with reason for med )

Taking Ibuprofen 200mg every 4 hours for her headaches.

PMH

Allergies: NKDA; No reported food or environmental allergies.

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: None

Family History

Father: 52 years old, Overweight, HTN

Mother: 56 years old, Overweight, Migraine headaches

Brother: 25 years old, Healthy

Sister: 26 years old, Healthy

Social History

Highest level of education: Master’s in Engineering

Occupation: Mechanical Engineer

Current living: Lives with her husband in an apartment

Marital status: Married for the past 3 years

Substance use/abuse: Denies use of any recreational drug, denies smoking tobacco or e-cigarettes

ETOH: Drinks at social events, twice a month, around 5 to 6 drinks

Safety Status: Works at an engineering firm, and occasionally has to work in the field, takes all safety precautions.

ROS

General

Denies fever, weight change, chills, fatigue, or change in energy

Cardiovascular

Denies Chest pain, denies palpitations, denies edema

Skin

Denies delayed healing, rashes, bruises, bleeding, skin discoloration, or lesions

Respiratory

Denies cough, denies wheezing, denies hemoptysis, and denies dyspnea.

.

Eyes

Reports eye pain and sensitivity to light during headache. Denies use of glasses or corrective lenses, denies blurring, double vision.

Gastrointestinal

Denies abdominal pain, constipation, diarrhea, hepatitis, eating disorders, or ulcers.

Ears

Denies ear pain, hearing loss, or ringing in the ears.

Genitourinary/Gynecological

Denies urgency, frequency, change in urine coloration. Sexually active with no contraceptive use. Denies STD’s. Last pap: 2018 -negative.

Denies menstrual complaints. LMP: 08/18/2020. Denies vaginal bleeding, or discharge

Nose/Mouth/Throat

Denies sinus complaints, denies dysphagia, denies throat pain, or hoarseness

Musculoskeletal

Denies muscle pain, denies limited range of motion.

Breast

Denies lumps, bumps, or changes.

Neurological

Reports headache with pain ranging from 6/10 to 8/10. Denies seizures, paralysis, weakness, or parasthesias.

Heme/Lymph/Endo

Denies easy bruising, denies night sweats, weakness, increased thirst, or increased hunger.

Psychiatric

Reports higher levels of stress beginning one month ago. Reports some anxiety. Denies depressive thought.

OBJECTIVE

Weight 147 lbs. BMI 22.3

Temp 97.9

BP 122/76

Height 68 inches

Pulse 81

Resp 17

General Appearance

Adult female, in no acute distress. Alert and oriented; answers questions appropriately.

Skin

Skin is warm, dry, clean, and intact. No lesions, bruises, or rashes noted.

HEENT

Normocephalic head, atraumatic, no lesions noted. Hair is evenly distributed.

Eyes: PERRLA, EOM’s intact, no scleral injection, no nystagmus.

Ears: Canals patent, bilateral TM’’s pearly gray, with positive light reflex.

Nose: Nasal mucosa pink, normal turbinate

Neck: Full ROM, no cervical lymphadenopathy, no occipital nodes.

Mouth/Throat: Oral mucosa pink, no exudates, teeth are in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Deferred.

Breast

Deferred

Genitourinary

Deferred

Musculoskeletal

Full ROM seen in all four extremities as the patient moved about the exam room.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

No labs conducted at this time.

Special Tests

No special tests at this time

Diagnosis

Final Diagnosis: Migraine (G43) The patient most likely is suffering from migraine headaches. These headaches are 3 times more likely in women than in men. The patient has the genetic factor due to her mom having migraines, and also working in a high stress environment. The patient also has light sensitivity during her headaches, and the patient also states that the pain worsens with movement. These are classical symptoms of migraine headaches (Migraine, 2020)

Differential: Primary Exertional Headache (G44.84) The patient may be experiencing an exertional headache. This is usually caused by strenuous activity such as intense exercise or can even be caused by coughing or sneezing.

Differential: Cerebral Aneurysm (I67.1) Common symptom of a cerebral aneurysm are headaches, eye pain, visual disturbances, and difficulty moving eyes (Cerebral Aneurysm, 2020). The patient reports headaches, and eye pain during the headaches, as well as light sensitivity.

Differential: Malignant Neoplasm of brain, unspecified (C71.9) Although few signs point to malignancy in this patient, this is a differential diagnosis that cannot be ruled out. Malignancy in the brain can cause headaches.

Plan/Treatment

The patient will be prescribed a higher dosage of ibuprofen. Ibuprofen 400mg to be taken every 4 hours as needed for pain. The maximum dosage is 3600mg per day. The medication should be taken as early as possible in the onset of the migraine headache to be as effective as possible. No other medication will be prescribed at this time, we will need to monitor the patient’s migraine to determine if they are chronic, or stress induced migraines. The patient can take additional non-pharmacologic steps in order to reduce pain (Migraine, 2020)

· Rest with your eyes closed, in a quiet, cool, and dark room.

· Place an ice pack, or cold water-soaked cloth on your forehead as you lay down.

· Drink plenty of fluids

· Stress management: Practice breathing exercises, anxiety control exercises.

· Exercises daily, but limit exercise to non-strenuous activity so no headaches are provoked.

Follow-up with the patient in 2 weeks to check if any migraines have occurred, and to re-evaluate and change treatment as necessary.