Episodic/Focused SOAP Note: Assessing Neurological Symptoms

Episodic/Focused SOAP Note: Assessing Neurological Symptoms

Episodic/Focused SOAP Note: Assessing Neurological Symptoms

Patient Information:

Initials: K.P

Age: 20 years

Sex: Male

Race: African American

Subjective

CC (chief complaint) “Headaches.”

HPI:  K.P is a 20-year-old male presenting with a chief complaint of headaches. The headaches began five days ago and are intermittent, with each episode lasting 5-15 minutes. He states that the headaches are diffuse all over the head and are throbbing in nature. However, the greatest intensity and pressure is felt above the eyes, and it spreads through the nose, cheekbones, and jaw. The headaches have no associated symptoms. However, he states that the headaches aggravated when he bends and during activity, affecting his daily activities. He has taken Tylenol to relieve the headache, and it eases the headache for some time. Rest also alleviates the headache, but this is ineffective since he has to work. He rates the headache severity as 5/10.

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Current Medications: OTC Tylenol 1gm for headache.

Allergies: No food or drug allergies.

PMHx: No history of chronic illnesses or surgical procedures. Vaccination is up to date; last TT-5 years ago, last Flu shot- 7 months ago.

Soc Hx: K.P is a 2^nd-year college student pursuing a Diploma in accounting. He was born and raised in Houston, TX, and is the 2^nd born in a family of three. His hobbies include playing basketball and horse riding. He admits to drinking vodka, mostly on weekends (2-3 glasses), and using recreational marijuana. He denies using tobacco or other drug substances. K.P reports having at least three meals and 2l of water per day. He sleeps 5-6 hours a day as he spends most of his free time watching basketball competitions and playing video games.

Fam Hx: The paternal grandmother has HTN and a history of stroke, and the grandfather has prostate cancer. The parents are alive and well, but the elder brother has asthma.

ROS:

GENERAL:  Negative for fever, chills, weight gain/loss, malaise, or fatigue.

HEENT:  Positive for headache, facial pain, and facial pressure. Negative for visual changes, excessive lacrimation, ear pain, hearing loss, sneezing, nasal discharge, or sore throat.

CARDIOVASCULAR: Negative for palpitations, ankle edema, chest pain, or dyspnea.

RESPIRATORY: Negative for chest pain, cough, shortness of breath, wheezing, or sputum production.

NEUROLOGICAL:  Positive for headache. Negative for dizziness, paralysis, syncope, or tingling sensation in the extremities.

Objective

Physical exam:

Vital Signs: BP- 118/78 mm Hg; Resp- 20; PR- 80; Temp- 98.78 F

Weight- 137 lbs.; Height- 5’5; BMI- 22.8

General: The patient is neat and appropriately dressed. He is alert and in no distress. He maintains eye contact and uses positive facial expressions. His speech is clear and goal-directed with normal rate and volume.

HEENT: Head: Symmetrical and normocephalic. Tenderness is present on the cheekbones, jawline, and orbital; the Frontal sinus is palpable. Eyes: Sclera is white; No excessive tearing; PERRLA. Ears: TMs shiny and clear; No ear discharge. Nose: Nasal septum is well-aligned; Tenderness on the nose bridge. Throat: Mucous membranes are pink and moist; Tongue is pink and midline; tonsillar glands are non-erythematous.

Cardiovascular: No edema or neck vein distension. Capillary refill- 1 second. Regular heart rate and rhythm with audible S1 and S2.

Respiratory: Chest is clear on auscultation and percussion.

Neurological: Normal gait, posture, and balance. Muscle strength-5/5; CNs are intact.

Diagnostic results:

CT of the Sinuses (Non-contrast): A CT scan is a major criterion for diagnosing problems in the sinuses. It will help identify the cause of tenderness over the sinuses and establish an underlying sinus inflammation causing the facial pressure (Maurya et al., 2019).

Assessment

Sinus Headache: Sinus headache occurs in persons with facial pain and is related to rhinosinusitis. It is characterized by throbbing or pulsating headache, nasal congestion, facial pain or pressure, and sinus congestion. Besides, sinus headache radiates to the sinuses, above the frontal, maxillary, or ethmoid sinuses (Maurya et al., 2019). The facial area is usually red, swollen, and tender on examination. Sinus headache is exacerbated by coughing, activity, and bending over. Sinus headache is a differential diagnosis supported by positive findings of throbbing diffuse headache and facial pressure above the eyes, spreading through the nose, cheekbones, and jaw (Maurya et al., 2019). The patient’s headaches are worsened by bending and activity, similar to sinus headaches. Tenderness on the cheekbones, jawline, and orbital area also suggests sinus headache.

Tension-Type Headache: Tension-type headache (TTH) is typically pressing or tightening, non-pulsating, and mild to moderate intensity. It is bilateral but not triggered or worsened by activity (Robbins, 2021). Patient findings consistent with TTH include diffuse bilateral headaches of moderate intensity. However, the patient has pulsating headache aggravated by activity, making TTH an unlikely primary diagnosis.

Cluster Headache: Cluster headache is a group of severe or very severe headaches occurring over some weeks. The headache is unilateral, and pain is perceived at the temporal, orbital, or supraorbital regions (Wei et al., 2018). Cluster headache is a differential diagnosis based on positive symptoms of headaches with great severity and pressure above the orbital, supraorbital, and temporal regions. Nonetheless, the patient’s headache is diffuse and is intermittent, ruling out cluster headache as a likely primary diagnosis.

Headache due to Refractive Errors (HARE): HARE is defined as mild headaches in the frontal region and orbital area. The headaches are worsened by extended visual tasks and are primarily associated with hypermetropia or astigmatism (Lajmi et al., 2021). HARE is a differential diagnosis based on the patient’s history of diffuse headaches occurring in the orbital area. However, the patient’s headaches are not attributed to visual tasks, hypermetropia, or astigmatism, making HARE an unlikely diagnosis.

Migraine Headache: Migraine headaches are usually unilateral, pulsating or throbbing, and aggravated by exertion. They last 4 -72 hours and can be very severe. The headache is localized in the ocular and front temporal areas but can occur anywhere around the head and neck. It is associated with nausea, vomiting, photophobia, and phonophobia (Robbins, 2021). Pertinent positive symptoms in line with a migraine headache include throbbing moderately severe headaches that are worsened by activity and having high intensity on the ocular area (Robbins, 2021). Nevertheless, the patient has a diffuse headache and no associated symptoms, making Migraine headache an unlikely diagnosis.

References

Lajmi, H., Choura, R., Achour, B. B., Doukh, M., Amin, Z., & Hmaied, W. (2021). Headache associated with refractive errors: Characteristics and risk factors. Revue Neurologique. https://doi.org/10.1016/j.neurol.2020.10.008

Maurya, A., Qureshi, S., Jadia, S., & Maurya, M. (2019). “Sinus Headache”: Diagnosis and Dilemma?? An Analytical and Prospective Study. Indian journal of otolaryngology and head and neck surgery: official publication of the Association of Otolaryngologists of India, 71(3), 367–370. https://doi.org/10.1007/s12070-019-01603-3

Robbins, M. S. (2021). Diagnosis and Management of Headache: A Review. JAMA, 325(18), 1874–1885. https://doi.org/10.1001/jama.2021.1640

Wei, D. Y. T., Ong, J. J. Y., & Goadsby, P. J. (2018). Cluster headache: epidemiology, pathophysiology, clinical features, and diagnosis. Annals of Indian Academy of Neurology, 21(Suppl 1), S3.https://doi.org/10.4103/aian.AIAN_349_17

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In this Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
To Prepare
By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
With regard to the case study you were assigned:
Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study you were assigned.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
The Case Study Assignment
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

CASE STUDY: Headaches

A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw

RUBRIC
Using the Episodic/Focused SOAP Template:
· Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned.
· Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.
45 (45%) – 50 (50%)
The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
30 (30%) – 35 (35%)
The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study and provides a thorough, accurate, and detailed justification for each of the five conditions selected.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
5 (5%) – 5 (5%). Uses correct APA format with no errors.