Case Study 1: Headaches

NURS 6512 Week 9 Case Study 1: Headaches

Episodic/Focused SOAP Note Template

Patient Information:

J.M a 20-year-old Male

S.

CC: Experiencing intermittent headaches

Case Study 1: Headaches

HPI: John is a 20-year-old male who comes to the hospital complaining of experiencing intermittent headaches. He explains that the headaches diffuse all over the head, but the greatest intensity and pressure occur above the eyes and spread through the nose, cheekbones and jaw.

He states that he has been having headaches, but they have become a concern for the past three days. He has been using Aleve to relieve the pain, but the headache returns after some time. He rates his pain at 8/10.

Current Medications: He has been on Naproxen (Aleve) 20mmg every 8-12 hours for the past three days for headaches.

Allergies:  He denies any food and drug allergies. Reports allergy to dust and pollen. Develops a runny nose, itchy eyes, coughs, and sneezes when exposed to these allergens.

PMHx: No history of surgeries. All immunizations are up to date. He was diagnosed with severe community-acquired pneumonia at 12 and was admitted for two weeks for close management and monitoring.

Soc Hx: He is single. Loves taking nature walks with his friends. He denies any tobacco use. However, he currently took alcohol at a friend’s party. He includes that his house does not have working smoke detectors. He uses a seat belt all the time.

Fam Hx: Paternal grandfather succumbed to RTA at 75. The paternal grandmother, 85, is diabetic and hypertensive. The maternal grandfather succumbed to cancer at 48, and the maternal grandmother, 83, is hypertensive. His father, 47, is an alcoholic. Mother, 45, is overweight. Has an elder sister, 24, who is asthmatic. His younger brother, 16, is overweight. His grandparent has diabetes.

ROS:

GENERAL:  Denies weight loss and chills. Reports some weakness, fatigue, and fever.

HEENT:  Eyes: Reports pressure and pain above the eyes. Denies drainage, dryness, itchiness, or visual changes. Ears: Denies ear pain, drainage, hearing changes or loss. Nose: Reports sneezing and nasal congestion. Throat: Denies throat irritation, pain, coughing, or pain in swallowing.

SKIN:  Denies skin, pain, rash/itching, swelling, and lesions.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. Reports fatigue

RESPIRATORY:  The patient reports an occasional runny nose, stuffiness, and nasal irritation. Denies changes in breathing pattern, productive cough, dyspnea, or chest pain

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination or hematuria.

NEUROLOGICAL:  Reports intermittent headache. Denies dizziness, syncope, paralysis, ataxia, numbness, or tingling of hands and feet. Reports bowel is full and no change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint stiffness or pain.

HEMATOLOGIC:  Denies any bruising, anemia, or bleeding.

LYMPHATICS:  The patient has no history of splenectomy. Denies enlarged nodes.

PSYCHIATRIC:  Denies history of depression or anxiety and other mental illnesses.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Reports allergy to dust and pollen. Develops a runny nose, itchy eyes, coughs, and sneezes when exposed to these allergens. Denies any food or drug allergy

Physical Exam: HEENT; Had: The head is normocephalic with no tenderness, lesions or rashes. There is no loss of hair, and the hairline is intact. The scalp is oily, and the skin is retractable. EYES: PERRLA, the sclera is white, no drainage, no pallor, pupillary light reflex. Visual acuity 20/20 bilaterally with no lenses. Nose: Grimace and complains of pain on palpation of the sinuses.

Neck: trachea midline, no enlargement of the thyroid gland, no scars, masses, or nodal enlargement

Chest: no palpitations or wheezes. Symmetrical rising on breathing, with no rashes or lesions. Resonance on lung percussion

Diagnostic results: Full hemogram (to detect any systemic involvement), WBC differentials (to diagnose infective causes of the presenting symptoms). X-ray and nasal endoscopy to detect sinus blockage

A.

Primary diagnosis: Sinusitis with a Sinus headache

Sinus headaches present with facial pain, exerting pressure on the eyes, cheekbones and jaws (Kim and Patel, 2020). Sinusitis is a sinus infection that occurs when fluid builds up in the sinuses. Common sinus infection symptoms include facial pain and pressure, runny nose, stuffy nose, and headache (CDC.gov, n.d.)  The patient presents with intermittent headaches.

The headaches diffuse all over the head, with the greatest intensity and pressure occurring above the eyes and spreading through the nose, cheekbones and jaws. Based on these signs and symptoms, the ultimate diagnosis is sinusitis and sinus headache.

Differential 1. Covid-19

Coronavirus disease (Covid-19) is an infectious disease caused by the SARS-Cov-2 virus. Some of the common symptoms of covid-19 include headaches, pains and aches, sore throat, cough, fever, and tiredness. The patient presents with an intermittent headache. Also, from the ROS, the patient reported having nasal irritation, which is one of the major presentations of Covid-19.

According to Toptan et al. (2020), covid-19 patients usually present with intermittent headaches, with the headaches causing facial pain and pressure. Thus, this could be one of the diagnoses. However, the patient does not present with other Covid-19 symptoms, such as fever, thus ruling it out as the primary diagnosis.

Differential 2. Migraines

Migraines are moderate or severe headaches that are felt as a throbbing pain from one side of the head. Migraines may be felt from the entire head, with varying intensity in particular parts. According to Munjal et al. (2020), different migraine patients present with headaches with intensity and pressure in different areas.

Additionally, the intensity of the headache pain is high. The reason why migraines could be the diagnosis is because the patient reports a severe headache, with a higher intensity and pressure around the eyes, the cheekbones and the jaws.

Differential 3. Rhinitis

Rhinitis is an irritation and swelling of the mucosal membranes in the nose. Rhinitis occurs when allergens in the air trigger a reaction in the eyes, nose or throat. Hoyte and Nelson (2018) note that the most common causes of rhinitis are pollen, dust, odors and fumes.

Some of the symptoms of rhinitis include a runny nose, congestion, and sneezing. Besides the headache, the patient complained of having a congested nose and running nose. In addition, he is allergic to dust and pollen, the highest causative allergens to rhinitis; thus, it could be the condition. Also, the headache could have been attributed to by nasal congestion and irritation.

References

Centers for Disease Control and Prevention. (n.d.). Sinus infection (Sinusitis). Retrieved from  https://www.cdc.gov/antibiotic-use/sinus-infection.html

Hoyte, F. C., & Nelson, H. S. (2018). Recent advances in allergic rhinitis. F1000Research7. https://doi.org/10.12688%2Ff1000research.15367.1

Kim, R., & Patel, Z. M. (2020). Sinus Headache. Otolaryngologic Clinics of North America. https://doi.org/10.1016/j.otc.2020.05.019

Munjal, S., Singh, P., Reed, M. L., Fanning, K., Schwedt, T. J., Dodick, D. W. & Lipton, R. B. (2020). Most bothersome symptom in persons with migraine: results from the Migraine in America Symptoms and Treatment (MAST) study. Headache: The Journal of Head and Face Pain60(2), 416-429. https://doi.org/10.1111/head.13708

Toptan, T., Aktan, Ç., Başarı, A., & Bolay, H. (2020). Case series of headache characteristics in COVID‐19: headache can be an isolated symptom. Headache: The Journal of Head and Face Pain60(8), 1788-1792. https://doi.org/10.1111/head.1394

Case Study 1 Assignment Instructions: Headaches

Case Study 1: 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. 

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.

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. 

NURS 6512 Week 9 Rubric

NURS_6512_Week_9_Assignment1_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning Outcome 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.

50 to >44.0 ptsExcellent

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.

44 to >38.0 ptsGood

The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.

38 to >32.0 ptsFair

The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected.

32 to >0 ptsPoor

The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.

50 pts
This criterion is linked to a Learning Outcome·   List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
35 to >29.0 ptsExcellent

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.

29 to >23.0 ptsGood

The response lists four to five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected.

23 to >17.0 ptsFair

The response lists three to four possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or some inaccuracy in the conditions and/or justification for each.

17 to >0 ptsPoor

The response lists three or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.

35 pts
This criterion is linked to a Learning Outcome 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 to >4.0 ptsExcellent

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.

4 to >3.0 ptsGood

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3 to >2.0 ptsFair

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.

2 to >0 ptsPoor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation
5 to >4.0 ptsExcellent

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 ptsGood

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 to >2.0 ptsFair

Contains several (3 or 4) grammar, spelling, and punctuation errors.

2 to >0 ptsPoor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

5 pts
This criterion is linked to a Learning Outcome 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 to >4.0 ptsExcellent

Uses correct APA format with no errors.

4 to >3.0 ptsGood

Contains a few (1 or 2) APA format errors.

3 to >2.0 ptsFair

Contains several (3 or 4) APA format errors.

2 to >0 ptsPoor

Contains many (≥ 5) APA format errors.

5 pts