Soap Note Analysis of Patient with Headache
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
Consider what history would be necessary to collect from the patient in the case study you were assigned.
During history taking, the patient should have been asked more about the headache. The examiner should have utilized SOCRATES to assess the headache more. According to Gregory (2019), SOCRATES mnemonic is a pain assessment tool that is widely utilized by healthcare providers to help them remember key questions about the pain. The onset, character, associated symptoms, severity, or the aggravating or relieving factors. The patient should have also been asked about any history of head injury, visual disturbances, dizziness, nausea, vomiting, photophobia, fever, sleep disturbances, neurological deficits, neck stiffness, temporal region tenderness, rash, or weight loss.
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?
According to Lee et al. (2018), physical examination is very crucial for patients with headaches to assist in ruling out secondary headaches. Physical examination of a patient presenting with headache will include monitoring of the vital signs of the patient, general appearance, general examination, and a full neurological examination. The scalp is examined for any swellings and tenderness, the ipsilateral temporal artery should be palpated, and temporomandibular joints should be palpated for tenderness and crepitance as the patient opens and closes the mouth.
Inspection of the periorbital area for any conjunctival injection, lacrimation, or flushing. The pupils are examined for size, response to light, extraocular movements, and the visual fields are also assessed. The fundi should be examined for spontaneous retinal venous pulsations and papilledema. The oropharynx should be inspected for any swelling, and the teeth are percussed for any tenderness. The neck is flexed to detect any stiffness or discomfort and the cervical spine is palpated for any tenderness.
According to Filler et al. (2019, February), diagnostic imaging workup for headache is very important in ruling out brain abnormalities or bleeding. Most patients presenting with headache do not require laboratory tests, but tests are important in diagnosing some conditions which present with headache and also those that are emergent.
A head CT scan and an MRI are neuroimaging studies which are utilized in patients with headache. Other important tests include a lumbar puncture and CSF analysis, ESR, and a full blood count test. These tests can be utilized to make an accurate diagnosis of a primary headache or a secondary headache type and the cause of the secondary headache.
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Sinus headache- According to Hutchinson (2016), sinus headache feels pressure around the eyes, cheek, and forehead.
Migraine headache- this is a condition where the patient experiences severe headaches which are on and off.
Cluster headache- this is the most prevalent headache disorder among trigeminal autonomic cephalgia and is common among young men.
Tension headache- it is described as a featureless headache since due to lack of associated symptoms, it is episodic but it rarely impacts daily life activities.
Idiopathic stabbing headache- this is a headache that is characterized by sharp, brief but is severe jabbing pain and it can occur anywhere in the head.
Soap Note Analysis of Patient with Headache References
Gregory, J. (2019). Use of pain scales and observational pain assessment tools in hospital settings. Nursing Standard. doi, 10.
Lee, V. M. E., Ang, L. L., Soon, D. T. L., Ong, J. J. Y., & Loh, V. W. K. (2018). The adult patient with headache. Singapore medical journal, 59(8), 399.
Hutchinson, S. (2016). Sinus headaches.
Filler, L., Akhter, M., & Nimlos, P. (2019, February). Evaluation and management of the emergency department headache. In Seminars in neurology (Vol. 39, No. 01, pp. 020-026). Thieme Medical Publishers. https://pubmed.ncbi.nlm.nih.gov/11480268/
Soap Note on Pain When Urinating Sample
| SOAP Note Form | |||
| S/ Identifying Information: (initials, age/DOB, gender, reliability) | Family Hx: | ||
| Mrs. P. T.65 yrs. FemaleReliable Historian | Paternal Grandmother and Grandfather are deceased with no known health histories. Maternal Grandfather, 105, is partially blind, diabetic, and hypertensive. Maternal Grandmother died at 65 of uterine cancer was diabetic and hypertensive. Faith died in a road accident at 40 was diabetic and hypertensive. Mother, 81, has diabetes. Brother, 48, is obese and diabetic. Sister, 44, is healthy with no compilations. | ||
| Personal/Social Hx : | |||
| Chief Complaint/RFE: | Denies alcohol intake, smoking, or illicit drug abuse. Marriage status: widow for the last five years. Living conditions: Lives alone in the house, son lives in the neighborhood and occasionally visits Occupation: She is a retired lab technician Hobbies: walking, hiking (limited due to old age), walking, reading books. | ||
| “I have been feeling pain when urinating.” | |||
| Hx Present Illness: (7 Variables but do not list as such) | |||
| Mrs. P. T. reports burning pain when urinating. She reports that her pain began three days ago as a mild discomfort which she rated 1/10 on a pain rating scale. The pain is not continuous, and it only appears during urination. The pain gradually increased, and she rates the current pain at 8/10. The pain interferes with complete urination hence voiding small frequent urine volumes causing more pain. The urine is clear but has a strong, pungent smell. The pain has also caused hesitancy when voiding. She complains she more frequently feels the urge to urinate after taking coffee or tea, and thus she avoids them and takes clear fluids such as water. She took some painkillers, paracetamol 1g PO, which provided temporary ineffective relief, so she stopped taking them. The pain is accompanied by inguinal lymph nodes pain and swelling. Pain persists after voiding, and the pain is aggravated by walking or stretching the abdomen, making daily living activities difficult. She reports fever denies sexual recent sexual contact, swimming, and any trauma to the genitalia. She denies any other symptoms. | |||
| CURRENT HEALTH | |||
| Medications: Insulin Regular Human/ neutral insulin/ soluble insulin Injectable insulin, 10 IU TDS. Indication: Diabetes Glucose regulation in a diabetic patient. class: HAntidiabetics, short-acting insulins. MOA: Insulin regulates blood sugar by stimulating peripheral glucose uptake into the cells, primarily the muscle cells and lipocytes. It also inhibits the production of glucose and its release by the liver. Insulin increases glycogenesis and the conversion of glucose into other forms and stimulates its storage. These actions reduce blood sugar in the circulatory system. Side effects: sweating, shakiness, hunger (hypoglycemia), tachycardia, tingling sensations, lured vision, confusion, attention deficit, mood changes, sleepiness, weakness, fatigue, and severe symptoms such as loss of consciousness, seizures, nightmares, and loss of coordination ((Świątoniowska et al., 2019). Patient education: Take your blood glucose reading before injecting insulin, use a different region every time to inject the insulin, avoid injecting a similar place twice consecutively, do not inject the medicine into an injured area with a bruise, scar, lump, scaly, or pitted. Eat a meal within thirty minutes of injecting regular insulin (Janež et al., 2020). | |||
| Allergies: Denies any food or drug allergy. Allergic to pollen, dust, and cats. Manifestation incl: sneezing, wheezing, running nose, coughing, headache, and red, itchy, and watery eyes | |||
| Last PE & Screenings: Last took a comprehensive PE 3 months ago, normal PAP. Reports a normal HgBA1c, foot, eyes, and other exams | |||
| Immunization Status: Reports having all childhood immunizations UPTD, COVID 19, tetanus, flu shot, and HPV vaccines | |||
| LMP & Birth Control (if applicable) Menopause at 46 | |||
| PMH | |||
| Illnesses & Trauma: Road accident at 35, broke both legs and prolonged immobility, hx of Diabetes controlled with dieting and insulin, no other illnesses | |||
| Hospitalizations/Surgeries: Hospitalized for fracture reduction, mobilization, and monitoring for 13 days. Had three caesarian sections, each two days hospitalization. Denies other hospitalizations | |||
| OB Hx/Sexual Hx: Sexually inactive since husband’s death, four years ago. History of treated genital warts at 32 | |||
| Emotional/Psy Hx: Reports mild depression and loneliness, denies anxiety and psychiatric disorders. | |||
| REVIEW OF SYSTEMS | |||
| General: Reports fever, pain, discomfort, and mild depression. Denies chills, night sweats, recent drastic weight loss, or weight gain. | |||
| Nutrition Cooks her food at home. Eats three meals and recommended snacks a day. Eats food low on salt, cholesterol-free, with no caffeine intake. | |||
| Skin/ Reports slight acne and hyperpigmentation. Denies skin rashes, lesions, tenderness, pain, or masses Hair/Nails: Denies infected, painful, brittle, discolored nails. Denies hair loss, excessive growths, or brittle hair | |||
| Head: Denies recent headaches, injuries, or concussions. Had a concussion at 32 Ears: Reports some hearing loss. Denies otorrhea, discharge, vertigo, tinnitus Eyes: Current visual changes but uses corrective lenses. Denies blurry vision, photophobia, pain, dryness, itchiness, or diplopia Nose: Denies smell sense changes, sinus pain, stuffiness, nasal drainage, congestion, sneezing Throat: Denies voice changes, dysphagia, gum pain/bleeding, toothaches, mouth ulcers or lesions, dysphagia. | |||
| Breasts: Denies breast pain, masses, nodules, pain, tenderness, galactorrhea, or discharge | |||
| Respiratory: Reports some non-productive cough, denies dyspnea, cyanosis, wheezing, | |||
| CV Denies chest pain, palpitations, fatigue at rest or little activity, edema, orthopnea, body weakness. Peripheral vascular Denies leg pain, swelling, redness, or weakness. | |||
| GI: Reports excruciating pain in the lower abd., pain voiding. Denies nausea, vomiting, hemorrhoids, hemoptysis, loss of appetite, melena, hematemesis, heartburn, hematochezia, or stool color changes | |||
| GU: Reports severe dysuria, increased frequency, hesitancy, flank pain, suprapubic pain, and loss in stream force. Denies vagina discharge, rashes, or lesions | |||
| MSK: Reports mild joint pain. Denies limited ROM, joint stiffness, swelling, redness, bone deformities | |||
| Psych: Reports mild depression and loneliness. Denies anxiety, mood changes, poor concentration, agitation, insomnia, hypersomnia, irritability, suicidal ideations, or attempts. | |||
| Neuro Denies fainting, seizures, malaise, tremors, memory loss, coordination difficulties, paralysis, or paresthesia. | |||
| Lymph/Heme/Endocrine: Reports pain in the inguinal lymph node. Denies other lymph pain. Denies bruising, diagnosed anemia, heat or cold intolerance, thyroid pain or tenderness, or polydipsia. Reports occasional polyphagia and polyuria | |||
| O/ Physical Exam: T: 37.1 P: 139/88 R: 88 BP: 92 HT: 160cm WT: 58kg BMI: 22.7 | |||
| General: Patient in generally fair condition, mildly stressed, fully oriented to person, time, space, and occasion, well dressed and groomed | |||
| Skin: slight acne and hyperpigmentations scattered over the face, old age wrinkles, no apparent trauma, lesions, rashes, swellings, breakages, or tenderness | |||
| Head: normocephalic, grey hair evenly distributed, no lesions, swelling, or masses. No tenderness, scars, or visible trauma. | |||
| Eyes: PERRLA bilaterally, visual acuity 20/20 right and left eye, no corrective lenses. Sclera white, pink conjunctiva No erythema, draining clear fluid (tears), no apparent injury, eyelashes pre4sent and raised. Ears: No swelling, rashes, or lesions. Ear drug grey and shiny, no drainage, erythema, or masses. No pain on palpation. Positive whisper test – hearing intact. Nose: Intact membrane, no nasal drainage, nasal mucosa pink, no inflammation. No pain on palpation of the sinuses, sense of smell intact, | |||
| Throat & Mouth: Ovule midline, taste intact, gag reflex present. No gum redness, bleeding, or pain. Lips pink, no dryness, Neck: Symmetrical neck, no apparent masses, lesions, tenderness. No pain on palpation, unpalpable cervical lymph nodes, trachea midline, unpalpable thyroids, symmetrical movement with swallowing, full range of motion | |||
| Breasts/Chest: breast exam deferred | |||
| Lungs: symmetrical chest movement, no accessory muscle use, quiet breathing with no crackles or wheezes on breathing, respiratory rate 18, resonance on percussion. | |||
| Heart/ perip vascular: Jugular vein not distended, no carotid bruits, carotid pulse 92. S1 and S2 heart sounds, no S3 or heart murmurs. Capillary refill <2 sec. No calf pain, no edema, femoral and radial pulse 92 | |||
| Abdomen: Round, CS scars with no other scars, no flank discoloration. Bowe sounds in all quadrants, no hepatomegaly, spleen, and kidney not palpable, tenderness and guarding on light palpation of the lower abdomen. | |||
| Genitalia/Rectum; deferred | |||
| Lymph: inguinal lymph nodes inflamed. Cervical, axilla, sub clavicular lymph nodes not palpable. | |||
| MSK: Posture and balance intact, all reflexes intact. Appreciable biceps, trapezius, triceps, hamstrings, and calf muscles. Has a tight hand grip | |||
| Neuro: Intact cranial nerves, posture, and balance appreciable, good speech, follows all instructions, intact long-term and short-term memories. | |||
| Medical Dx: (2max) R30.0 Dysuria | Rule Outs (only if applicable): | ||
| Health Profile: | |||
| Age/gender/racial risks: Elderly + Female: exposed to health conditions common in old age. Older adults generally have lower. Females are more exposed to UTIs due to a shorter urethra. | |||
| Pertinent Positives:(1DX) Severe dysuria, increased frequency, hesitancy, flank pain, suprapubic pain, loss in stream force, and pain in the inguinal lymph node | |||
| personal/family: None | |||
| screening needs: None | |||
| Pertinent Negatives: She denied recent sexual intercourse, history of STIs, persistent pain, trauma to the pelvis, vagina discharge | counseling needs: None | ||
| Immunization/chemo needs: None | |||
| Differential DX: (3-5): A64 STIs, N30. 9 Cystitis,N77.1 Vaginitis, Z18. 9 Foreign body (for example kidney stone), S39.93XA Pelvic Trauma | Alteration in Health Prevention R/T: | ||
| Screening deficits: None | |||
| Counseling deficits: None | |||
| Nursing Dx: Impaired urinary elimination related to pain during urination as evidenced by frequent urination of small volumes | Immunization/chemo deficits: None | ||
| I. PLAN: Do separate sections in the plan to include: Max 1-2 pages Diagnostics: Dysuria in Uncomplicated Cystitis Medications/Treatments: Nitrofurantoin 100mg twice daily for five days, Trimethoprim 200mg twice daily, Fosfomycin oral 2g STAT dose, and paracetamol 1g TDS 3 days. Cleaning the perineum with clean water only at least three times every day. Urinalysis, blood culture, and cytology to confirm or rule out the diagnosis. Education: Take copious amounts of water. Wipe yourself from the front to back after voiding. Void often, avoid hesitancy which can exacerbate an infection and delay wound healing. Always observe the color and smell of your urine. Come back if the pain persists, urine changes color, or there is blood or urethral discharge after the treatment regimen. Follow-up: To come again after two weeks for follow-up care. Should come back if she stops blood in urine or pain increases before the return date. Referrals: Refer for lab works such as culture and sensitivity and cancer screening to rule out other causes such as neoplasms. Prevention Plan: Stay hydrated urinate anytime you feel the urge. Wipe from the front to the back. Avoid washing the perineum with soap; clean with clean water alone at least three times a day. |
| II. Rationale: ( Max 2 pages)Dysuria is the diagnosis of choice majorly due to the under involvement of vaginal and other reproductive system structures. The woman also reports no sex encounter recently, hence ruling out STIs (Bradley et al., 2019). The pain may result from infections of the urinary tract without kidney involvement. Nitrofurantoin is the drug of choice for treating urinary tract infections due to difficulty with antibiotics treatment in older adults (Bradley et al., 2019). In addition, the drug of choice must have active metabolites excreted through the kidney. Additional tests such as blood culture will help identify the causative organisms hence effective treatment. It will also help rule out other conditions (Kornfält et al., 2021) |
| III. Patho: (Max 2 pages) Dysuria is common among older females due to various reasons. The most common cause of dysuria is cystitis, followed by STIs. Infection in the female reproductive system results from a short urethra and decreased immunity (Bradley et al., 2019). Infections cause lacerations of the urinary tract, and the acidic urine causes pain as it passes the exposed areas. Adherence of urethra and bladder walls after emptying causes excruciating pain hence the reluctance to void common in dysuria. |
Soap Note Analysis of Patient with Headache References
- Janež, A., Guja, C., Mitrakou, A., Lalic, N., Tankova, T., Czupryniak, L., … & Smircic-Duvnjak, L. (2020). Insulin therapy in adults with type 1 diabetes mellitus: a narrative review. Diabetes Therapy, 11(2), 387-409. https://doi.org/10.1007/s13300-019-00743-7
- Świątoniowska, N., Sarzyńska, K., Szymańska-Chabowska, A., & Jankowska-Polańska, B. (2019). The role of education in type 2 diabetes treatment. Diabetes research and clinical practice, 151, 237-246. https://doi.org/10.1016/j.diabres.2019.04.004
- Bradley, M. S., Beigi, R. H., & Shepherd, J. P. (2019). A cost-minimization analysis of treatment options for postmenopausal women with dysuria. American Journal of Obstetrics and Gynecology, 221(5), 505-e1. https://doi.org/10.1016/j.ajog.2019.04.031
- Kornfält, I. H., Hedin, K., Melander, E., Mölstad, S., & Beckman, A. (2021). Uncomplicated urinary tract infection in primary health care: presentation and clinical outcome. Infectious Diseases, 53(2), 94-101. https://doi.org/10.1080/23744235.2020.1834138
Also Read: Soap Note on Patient with Bipolar Disorder