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. Provide evidence from 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. Focused SOAP Note Essay Example
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.
S-SUBJECTIVE
Chief Complaint: “I have been having sporadic headaches, but the pain and pressure seem to be greatest above the eyes; the pain tends to spread over the cheekbones, nose, and jaws”.
HPI: A 20-year-old Caucasian male presented and reported intermittent headaches for the last 5 days. AK added that the pain diffuses throughout the head, but the pain and pressure intensifies above the eyes, spreading via the nose, cheekbones, and jaws. The patient further reported that the pain becomes worse when he leans over or with the sudden movement. Exercise worsens the headache. The client also reported that his nose felt stuffy while his ears felt stuffed. Focused SOAP Note Essay Example
Location: Head
Onset: 7 days ago
Character: Pressure-like pain that is greatest around eyes, spreading via the nose, cheekbones, and jaws, pressure around the eyes
Associated signs and symptoms: Stuffy nose and stuffed ears
Timing: Intermittent
Exacerbating/ relieving factors: The pain becomes worse when he leans over, with exercise or with the sudden movement. Utilizes Ibuprofen as the pain reliever.
Severity: 8/10 pain scale
Current Medications: Uses Ibuprofen whenever the pain becomes unbearable
Allergies: None
Past Medical History (PMH): None
Past Surgical History (PSH): None
PMHx: The immunizations for the patient are up to date. His last TT vaccination 22nd March 2020. His flu shot is up to date.
Personal/Social History: Single; college student; works part-time in a hotel; lives with his parents and two daughters; no alcohol or substance use.
Family history: The mother has diabetes type 2; father is hypertensive and has a history of sinuses
Lifestyle: The patient is an active rugby player at the local club
Review of Symptoms:
General: The patient looks well dressed and denied any recent weight changes. The patient looks fatigued and in pain.
Head: Intermittent headaches
Eyes: Pain and pressure in the eyes
Ear: Stuffed ears
Chest: No cough, no pain
Heart: Normal pulse rate, no palpation
Respiratory: Pain in the nose; puffy nose
Gastrointestinal: No diarrhea, no abdominal pain
Urinary: No pain during urination; no urinary tract infection
Musculoskeletal: No joint pain or muscle pain
Skin: No blemishes or spots on the skin
Psychiatry: Sleep disturbances due to the headache; no mental disorders
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Neurological: Reported dizziness; no weakness; no seizures.
Endocrine: No metabolic problem
Immunologic: No immune deficiencies.
Hematologic: Normal Hb level; no history of blood transfusion
Allergic: No allergies
O- OBJECTIVE
Vital signs: Temperature – 37.0° C; Blood pressure- 122/84; RR- 18; and Pulse rate- 70; SPO2 100%; Weight, 69 kgs
General: The patient appears alert and fully oriented to place, time, and person. He is well-groomed, and appropriate weight for his age. He keeps gleaning, perhaps due to the pain.
HEAD: The scalp is clean
Neck: Normal
Chest/Lungs: Normal breathing rate, no palpation, clear to auscultation
Heart: Normal pulse rate and rhythm
Neurological system: The GCS 15/15; Lower extremity reflexes score +2/4
Lab/Diagnostic Tests
- Nasal endoscopy: The rationale of this test is to examine the nose and perform a visual inspection of the sinuses. This test is useful in confirming or ruling out sinus headache
- MRI: An MRI will help to inform if a serious problem such as a brain tumor is the cause of the headache (Prakash & Rathore, 2016). Focused SOAP Note Essay Example
ASSESSMENT:
Differential Diagnosis (DDx):
- Sinus headache: Sinus headache occurs around the eyes, cheekbone, nose, jaw, and forehead. The pain is deep and constant. The headache is also accompanied by fever, nasal discharge, and a feeling of puffiness on the face and ears (Petersen et al, 2019). The patient reported a headache that spreads to the eyes, nose, cheekbones, and jaws and thus this confirms the diagnosis of sinuses.
- Migraine headache: Migraine headache normally manifests on one side of the head and there is pressure behind one of the eyes. The pain is normally throbbing and worsens with activity. The pain gets worse with light and noise and is accompanied by vomiting and nausea (Lee et al., 2018). The pain on this patient diffuses in the whole head; the differential diagnosis of migraine is thus ruled out.
- Tension headache: Tension headache occurs on both sides or all over the head and it is accompanied by deep and pressing headache. The pain does not worsen with physical activity. This type of headache does not spread to the nose and cheekbones and thus the diagnosis of tension headache for this client is ruled out (De Corso et al., 2018).
- Cluster headache: Cluster headache occurs on one side of the face, head, or neck, without spreading to any other side. The pain the client is manifesting spreads through the whole head; the diagnosis of cluster headache for this client is ruled out (May, 2018).
- Trigeminal neuralgia: Trigeminal neuralgia is abrupt and manifests as stab-like pains. The pains are caused by mechanical or sensory stimuli. The pain for this patient was not caused by mechanical or sensory stimuli; the diagnosis of trigeminal neuralgia is thus ruled out.
Final Diagnosis: Sinus headache
PLAN
Treatment Plan
Ibuprofen: The client continued taking ibuprofen as the pain reliever for the headache
Saline nasal spray: The patient can use the nasal spray to spray on the nose and rinse the nasal passages
Nasal corticosteroids: Fluticasone nasal corticosteroids spray will assist in preventing and treating inflammation for this patient (Lee et al., 2018).
Health promotion
The patient was advised to take enough rest to help his body fight the infection. He will also be advised to keep hydrated and moisten the sinus cavities by breathing in warm and moist air. This will ease the pain and drain the mucus. The patient will be instructed to rinse his nasal passages using a sinus rinse to assist clear his sinuses. Finally, he will be advised to avoid allergic triggers likely to cause sinuses and headaches (Prakash & Rathore, 2016).
Follow up plan: The patient will attend the review clinic after 1 week to assess his progress and response to the prescribed treatment.
References
De Corso, E., Kar, M., Cantone, E., Lucidi, D., Settimi, S., Mele, D., Salvati, A., Muluk, N. B., Paludetti, G., & Cingi, C. (2018). Facial pain: sinus or not? Acta otorhinolaryngologica Italica : organo ufficiale della Societa italiana di otorinolaringologia e chirurgia cervico-facciale, 38(6), 485–496. https://doi.org/10.14639/0392-100X-1721.
Lee, V., Ang, L. L., Soon, D., Ong, J., & Loh, V. (2018). The adult patient with headache. Singapore medical journal, 59(8), 399–406. https://doi.org/10.11622/smedj.2018094.
May A. (2018). Hints on Diagnosing and Treating Headache. Deutsches Arzteblatt international, 115(17), 299–308. https://doi.org/10.3238/arztebl.2018.0299.
Prakash, S., & Rathore, C. (2016). Side-locked headaches: an algorithm-based approach. The journal of headache and pain, 17(1), 95. https://doi.org/10.1186/s10194-016-0687-9.
Petersen, S. M., Jull, G. A., & Learman, K. E. (2019). Self-reported sinus headaches are associated with neck pain and cervical musculoskeletal dysfunction: a preliminary observational case-control study. Journal of Manual & Manipulative Therapy, 27(4), 245-252.
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.
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.
Focused SOAP Note Essay Example