Using this template, complete one SOAP note from a patient in your current NSG6440 clinical experience. The completed note should be submitted to the Submissions Area.
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.
Evaluation of Encounter:
I assessed this patient independently of my preceptor. The preceptor contributed around 5% of this encounter and introduced the patient. After the introduction, I had complete autonomy in this visit. I conducted the ROS, as well as the physical examination. I also obtained this patient’s history, and took their vital signs including height and weight.
Weaknesses: I feel like I took too much time to diagnose and evaluate this patient. Some aspects of the physical exam may have been deferred.
Strengths: I quickly established rapport with the patient, and she felt confident in me to discloses any aspects of her health and family history, as well as the present medical issue and chief complaint. Due to this, we had a smooth interaction.
Reflection: I feel very ready to see patients without the supervision of a preceptor. This course has helped me achieve this confidence, and I am excited to start.
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