SOAP Note

SUBJECTIVE

Chief Complain: For this assessment, let us consider the case of A.C., a 20-year-old white female college student who just complained of persistent headaches that she has been experiencing in the past month. She said the discomfort was classified as mild to severe, throbbing at times, accompanied by occasional vertigo and nausea. She began having headaches after an accident in a motor vehicle where she had a head injury. She states that there is no stressor causing any distress to her and she has taken Ibuprofen with little effect. She was prescribed Midrin earlier but the prescription wasn’t filled due to forgetfulness as indicated in the video. Due to the headache, she has issues with focus during class and work.

DIFFERENTIAL DIAGNOSES/RATIONALE:

1. Headache: Particularly, A.C. is in university and might be facing significant stress to accomplish, resulting in a tension migraine, known to be the most typical kind of headache.
2. Brain tumor: A.C. reportedly experienced a headache for an entire month and may be suffering from malignancy or another brain disease. Headaches are the first complaint in one-half of individuals with cancer of the brain.
3. Meningitis: A.C. is a college undergraduate who may have been subjected to a viral disease that causes meningitis. This is a low possibility since the headache has been present for a month and meningeal migraines are more severe. However, this will continue to be a possible diagnosis until further information is gathered.

HPI: A college student, 20 years of age has a headache now for one calendar month and the intensity varies from dull to pounding; the subject rated it 3-8 on a scale. The headache ranges from the back of her head to the top of her head Although sometimes, the pain is coupled with dizziness and nausea, it is not accompanied by signs such as Photophobia, Blurred vision or any other neurological features. Ibuprofen use has offered her little comfort and Midrin was prescribed three weeks ago but she has not filled it because she forgets. Since then, she has experienced aching, which may be throbbing occasionally and interfere with concentration in class as well as at work. The headache does not wake her up though, it may be present at night depending on the time it started, and it is a rather ruminating headache that occurs at different times of the day. She links headache development to a car accident four weeks before, when as a seat-restrained passenger, she banged her head against the seat.

ROS:

Head: “Headache.”

Eyes: “denies visual loss diplopia, redness or drainage.”

Ears: “denies hearing changes, tinnitus, vertigo, drainage, or pain.”

Nose: “denies discharge, inflammation, obstruction, or epistaxis.”

Mouth: “denies sores, bleeding, toothaches.”

Throat: “denies sore throat, voice changes, hoarseness.”

Neck: “denies stiffness, swelling, or pain.”

Respiratory: “denies SOB, cough, wheezing, pain.”

Cardiovascular: “denies CP or tightness, palpitations, DOE, edema, claudication, or history of the heart murmur.”

GI: “denies N/V/diarrhea/ constipation, abdominal pain, change in bowel habits, bloody stools, or rectal pain.”

Genitourinary: “denies dysuria, hematuria, pain. Menstrual- denies dysmenorrhea, previous pregnancies, sexual activity, or previous venereal diseases. LMP 2 weeks before this visit.”

Neurologic: “denies smell changes, taste changes, hearing, speech changes, swallow difficulty, weakness, paralysis, tremors, seizures, paresthesia’s, or confusion. She has been sleeping “a lot”, goes to bed at midnight, rises at 7 or 9 am, naps daily.”

OBJECTIVE:

Vital Signs: Weight 179 lbs, Height 65 inches, Temperature 99.2°F, Pulse 76, Respirations 20, BP 114/72.

Physical Exam: Normal head and neck exam, intact cranial nerves, no signs of trauma or tenderness. Full range of motion in the neck and normal strength and sensation in extremities.

ASSESSMENT AND PLAN:

1. Post-traumatic headache:

According to the patient’s history and complaint, the most probable cause is post-traumatic headache, which may be due to the motor vehicle accident the patient had four weeks before the current visit to the clinic. It is also supported by other long-lasting symptoms or signs like dull to pounding headache, occasional dizziness, and nausea without any other neurological abnormalities. An emergency appointment for an MRI of the brain has been arranged to check for more severe conditions such as subdural hematoma or a brain tumor that would be fatal. In any case, if an MRI has not been done, the tentative diagnosis code will be post-concussional syndrome (ICD 310.02). Management involves the administration of Motrin 800 mg for the pains and Midrin for the severe breakthrough pains for which the patient has been directed. Explaining that headaches are rather common after traumatic brain injury and may last for weeks to months, patients were informed that most individuals with CBI get better as time goes by. The patient also seemed to comprehend and take solace in the scheduled MRI for a conclusive diagnosis. The patient will return for a review of MRI results and treatment response within one week time or sooner in case of emergent results.

1. Health Maintenance:

To A.C., all aspects of health must be addressed because of her age. Details regarding her immunization history like DTP, MMR, varicella, and polio should be assessed to ensure she received these vaccines on time. Based on her college, a Hepatitis B vaccine may be administered if she is taking health science or if she is likely to come into contact with infected persons. Vaccination against meningitis should also be administered, especially since college students are at a higher risk of developing the disease. One is keen on establishing the date when she underwent a pelvic exam with a pap smear; highlighting that women should be encouraged to undertake pap smears every three years from the time they started being sexually active or at the age of 18 years. Persons with low socioeconomic status or those who have several partners in a year might need more frequent tests. Prevention of STDs and contraception is a crucial issue to be discussed. Encouraging the use of seatbelts and helmets during activities such as driving, biking, motorbike riding or ATV riding is crucial in preventing injuries. Healthy dietary practices include low-fat and cholesterol diets and pyramid dietary plans aimed at taking balanced calorie intake through taking fruits, vegetables and grains. The promotion of a moderate level of physical activity and adequate amounts of calcium is beneficial to the health of all individuals. These measures will seek to ensure that A.C.’s ongoing and future health care and preventive needs are met efficiently.

About A.C. she underwent a pap smear within the past year, she stated that has no sexual intercourse currently but she is willing to use a condom in case of STDs and may decide on contraception in case her status changes. Her immunizations are up to date and told her about the meningitis vaccine for students at ECU. A.C. always wears a seat belt and was counselled to wear a helmet in cases she invades in activities such as cycling or riding a motorcycle. Her diet is of balanced meals but with intercalations of snacks such as sodas and chips. It was suggested to decrease the amount of soda and chips she drinks or eats and increase the intake of fruits and vegetables. A.C. has not been exercising this semester contrary to previous summers when she exercised in ECU gym. The recommendation was made to try and gradually increase her level of exercise if her headaches allow it.