Episodic Soap Note Headaches Paper

ByLeon Kiprotich Leon Updated on

Episodic Soap Note Headaches Paper

Patient: A-K
Sex: Male
Age: 20
Race:
CC:  Headache

History of Presenting Illness:

The 20-year-old male patient presents with headaches that are intermittent. The headache is diffuse and occurs all over. The patient reports that the pain has the greatest intensity above the eyes, nose jaw and around the cheekbones.

The timing of the headache. I would want to know for how long the patient has had the headache. Primary headaches usually exist for a longer time compared to secondary headaches. Acute headaches can be associated with subarachnoid hemorrhage or an acute hypertensive crisis. I would also want to ascertain the duration of each attack

It is important to know whether there are any associated symptoms, such as nausea, photophobia, phonophobia, visual auras, and vomiting. Vomiting can be a feature of a migraine. The character of the headache is also a useful pointer. Migraines can present as a throbbing and pulsatile headache (Lakhan, 2018). Tension headaches are dull. Exacerbating and relieving factors can give pointers as to whether there are any triggers. Headaches can be worsened by posture and relieved by lying down

Another thing to find out is the severity of the headache. The patient should score the headache on a verbal rating scale of 1-10 with 10 being the most severe. Migraines tend to be severe compared to tension headaches. It is however important to note that the pain from a primary headache can be as disabling as that due to a secondary headache.

Current medications:

I would want to know any medications the patient takes. This includes the medications that the patient takes to relieve the headache, the number of tablets taken and the duration. This is relevant as certain medications have headaches as a side effect. An example is sildenafil which is vasodilator. Coronary vasodilators can also cause hypotension which may present as headache. Also, overuse of analgesics can result in chronic headaches (Vandembussche et al, 2018).

Allergies: 

I would want to know if the patient has any allergies. Allergies may cause rhinorrhea and sinusitis.

Past Medical Hx:

For past medical history, it is relevant to know if the patient has any chronic illnesses. These include hypertension and diabetes. Diabetes can present with headaches such as in episodes of hypoglycemia. An acute hypertensive crisis can also present as a headache. I would also want to know if the patient has a history of recent trauma as this may present as headaches especially if the patient has a raised intracranial pressure.

Social Hx:

I would also want to know about the patient’s personal habits such as alcohol and tobacco use. Alcohol can aggravate cluster headaches. Heavy caffeine use is also associated with headaches

Family hx:

It is important to know if the patient has a history of similar headaches to his or any headache at all in the family (Sufrinko et al., 2018)

ROS:

On the review of systems, I would ask for;

GENERAL:  Any recent illness, fever, chills, night sweats, weight loss or gain.

HEENT:   Any visual loss, blurred vision, double vision, light sensitivity during headaches or yellow sclerae. Ears: pain, hearing loss. Nose: seasonal rhinorrhea sneezing, congestion, pain in sinus area during headaches, or runny nose. Throat: Sore throat, difficulty speaking or swallowing.

SKIN: Rash, or itching.

CARDIOVASCULAR: Chest pain, chest discomfort, palpitations and edema.

RESPIRATORY:  Cough or shortness of breath,

GASTROINTESTINAL:   Anorexia with headaches, nausea, and vomiting.

GENITOURINARY: Burning on urination

NEUROLOGICAL: Dizziness, syncope, numbness or tingling in the extremities, paralysis, changes in bowel or bladder control.

MUSCULOSKELETAL:  Muscle pain, joint pain, or back pain

HEMATOLOGIC: Anemia.

LYMPHATICS:   Enlarged nodes.

PSYCHIATRIC:   History of depression and anxiety.

ENDOCRINOLOGIC:   Excessive thirst, polyphagia, or polyuria.

ALLERGIES: History of asthma, rhinitis, or seasonal allergies

Physical exam:

General: The vital signs should be measured. This includes the heart rate, the blood pressure, the respiratory rate and the temperature. The temperature is useful in detecting whether there is a fever which can be an indication of an infection. The SpO2 on room air should also be checked.

Head and Neck: Check for the full range of motion. Meningitis can present with neck stiffness and headache (Young & Thomas, 2018). Also, check for head symmetry and any signs of trauma. Examine the scalp for areas of swelling and tenderness.

HEENT: Inspect the eyes and periorbital areas for any signs of lacrimation and flushing. Check the pupillary size and light responses. Check the nares for purulence, bleeding, rhinorrhea. Check for swallowing difficulties or hearing loss

Cardiovascular: Check for heart rate, heart rhythm, heart sounds, and any added sounds

Respiratory: Auscultate the lung fields for breath sounds and for respiratory rate.

Gastrointestinal: Palpate for abdominal tenderness or pain. Auscultate all 4 quadrants for bowel sounds.

Neurological: Assess whether the patient is well oriented to place time and situation. Assess the memory, Both short-term and long-term. Check the muscle tone.

Diagnostic results:

The necessary diagnostic tests include a CT scan of the head is done to rule out secondary causes of headache

A Complete Blood Count (CBC). headache is one of the symptoms of anemia therefore this should be ruled out.

Erythrocyte Sedimentation Rate (ESR). This is done to determine whether there is an inflammation such as temporal arteritis which can present as headache.

Nasal smear to look for eosinophils. This would confirm the presence of allergic rhinitis (Farrer, 2018).

Differential Diagnoses

Acute Sinusitis: Acute Rhinosinusitis causes symptomatic inflammation inside the nasal cavities lasting less than four weeks. It is a common complaint of frontal headaches, with pressure or fullness feeling. This disorder is usually worse during winter (Farrer, 2018).

Medication rebound headache: This is a chronic daily headache associated with medication or caffeine use. Pain with this headache is often described as diffuse. It is associated with person’s using headache medication or caffeine intake on a daily basis. This type of headache starts a few hours after the last dose of medication or caffeine (Vandembussche et al, 2018).

Migraine without aura: This is one of the most common complaints that patients present with. It is a very common disorder (Yeh et al., 2018). Headache is usually unilateral and described as throbbing. Migraines often are accompanied by photophobia, phonophobia, nausea, and vomiting.

Tension Headache: This type of headache is very common in adults. It presents as a mild to moderate headache that is band-like and develops gradually. It is usually associated with stress and can last from a few hours to a day (Dwyer, 2018).

Bacterial Meningitis. The patient’s chief complaint is headache and therefore this is a possible diagnosis. Meningitis usually presents with headache as one of its major symptoms (Young & Thomas, 2018).

References

  • Dwyer, B. (2018, December). Posttraumatic headache. In Seminars in neurology (Vol. 38, No. 06, pp. 619-626). Thieme Medical Publishers.
  • Farrer, F. (2018). Is it an allergy or is it sinusitis?. SA Pharmacist’s Assistant, 18(3), 25-26.
  • Lakhan, K. J. (2018). “Sinus” Headaches: Sinusitis Versus Migraine. Physician Assistant Clinics, 3(2), 181-192.
  • Sufrinko, A., McAllister-Deitrick, J., Elbin, R. J., Collins, M. W., & Kontos, A. P. (2018). Family history of migraine is associated with posttraumatic migraine symptoms following sport-related concussion. The Journal of head trauma rehabilitation, 33(1), 7.
  • Vandenbussche, N., Laterza, D., Lisicki, M., Lloyd, J., Lupi, C., Tischler, H., … & Katsarava, Z. (2018). Medication-overuse headache: a widely recognized entity amidst ongoing debate. The journal of headache and pain, 19(1), 1-14.
  • Yeh, W. Z., Blizzard, L., & Taylor, B. V. (2018). What is the actual prevalence of migraine?. Brain and behavior, 8(6), e00950.
  • Young, N., & Thomas, M. (2018). Meningitis in adults: diagnosis and management. Internal medicine journal, 48(11), 1294-1307.