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SOAP Note – Migraine
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Common Illness Across The Lifespan-Clinical Practicum
Professor
SOAP Note – Migraine
SUBJECTIVE DATA
Patients ID: Mrs. Olivia Roberts, Age: 68 years old, Race: Caucasian, Gender: Female,
Date of Birth: November 12, 1954, Marital Status: Windowed. The patient seems apprehensive but in good shape. She is a reliable historian.
CC: “I have been experiencing severe headaches that have persisted for four days. The headaches are so strong since they have raised a feeling of nausea and (seeing stars)”
History of Present Illness: Mrs. Roberts is a 68-year-old Caucasian female who visits the clinic with complaints of severe headaches. She explained that the headache was excruciating, having persisted for several days. She explained that headaches cause her a state of restlessness; therefore, she felt the essence of getting a medical examination. The patient explained that since her college days, she had not experienced such headaches. She described the pain from the headaches to be severe, rating it at 9/10 on a pain rating scale where it posits a throbbing sensation in her temporal region. She added that the pain began a few months ago, and it has been gradually worsening over time. The patient described the headache to be serious since, the past few days. She verbalized that she has been using ibuprofen to reduce the difficulty of the pain, but the drugs seem not to work anymore. The patient reports that the pain eases when she is in cool, silent, and mostly dark places while the pain aggravates in the presence of noise and light. This has been denying her the opportunity to catch up with her favorite television program and the NBA league since she is a great fan.
Review of Systems
Constitutional: The patient is friendly and seems a reliable historian on account of her extant and past medical histories. She is in good shape with no significant medical issues bothering her. She reverts unaccounted weight loss or gain, fever, nausea, chills, vomiting, or increased weakness.
HEENT: Head; reports severe headaches that causes a throbbing sensation on her right temporal region. The condition incites dizziness while standing and sensitivities to light and loud music. Eyes; experiences double vision at times with spots. Ears; reverts epistaxis and tinnitus. Nose; denies running nose or nasal congestion. Mouth and throat; Denies sore throat, nodes, swollen glands, or cold sores. Denies bleeding gums or dental deformities.
Skin: Reverts skin rashes, bruises, itching, lesions, or skin colour changes.
Pulmonary: Denies challenges with breathing, wheezing, coughs, or congestion.
Cardiovascular: Denies irregular heartbeats, chest tightness, pain, laboured breathing, or heart murmurs.
Gastrointestinal: Denies changes in bowel patterns, abdominal pain or discomforts, vomiting, constipation, diarrhoea, loss of appetite, but reports that she has been experiencing nausea due to the headaches.
Genitourinary: Denies changes in urinary frequency, pain upon urination or a burning sensation, smelly urine, irregular menses or vaginal discharge.
Musculoskeletal: Reverts injuries or trauma, joints weakness or stiffness, muscle cramps, swellings, or pain in the extremities. Also denies back pain or discomforts.
Lymph/Hematologic: She denies excessive bleeding, bruising, and petechia. Denies lymph nodes that are swollen, enlarged, or painful.
Neuro/Psych: She denies numbness or paraesthesia. Reverts sadness, depression, suicidal ideation, However, she said that the persistent headaches had affected her sleeping habits.
Past Medical History: The patient reported that she has no significant health conditions bothering her in the present, and neither did she have one in her young life. She also added that she has never been hospitalized.
Surgical: Underwent a C-section at age 28 and 31 in the delivery room.
Allergies: Reports no known allergies.
Medications: Been using ibuprofen 400mg 2 tablets a day to relent the headaches.
Immunization: Up to date with her immunizations where she received flu and yellow fever jabs in October. Also indicates that she is tolerant to vaccines.
Family History: Maternal grandparents deceased due to old age-related complications, but they were free of comorbidities. Paternal grandparents were also deceased. The grandfather was subject to Alzheimer’s, but the grandmother was healthy. The mother is alive, aged 92, and she suffers from hypertension and Type II diabetes. Her father died at the age of 90 due to complications attributed to Alzheimer’s. Her husband is alive, aged 72, and he is healthy not affected by any medical condition. Their two sons are alive, aged 37 and 40 years, and they are not affected by any health issues.
Social History: The patient lives with her husband, two grandsons, and two house helps in their own home in Seattle. She is retired from her work duties, where she served as a marine in the United States forces till the age of 65. The husband was an engineer, but he is also retired. They are financially stable. She denies the use of tobacco or recreational drugs. The patient drinks wine at social occasions and special events, but otherwise, she is sober. In her leisure time, she likes swimming, jogging, and yoga, but the headaches have limited her from her routine of exercise. She maintains a healthy dietary plan and abides by her nutritionist’s diet recommendations. She is sexually active. The patient is a Christian and goes for services every Sunday in her local church.
OBJECTIVE DATA
Vital Signs: Temperature: 98.0 ℉, Pulse: 84, Respiratory Rate: 18, Blood pressure 124/82, Oxygen saturation: R.A 96%, Height 5’.7’, Weight 130 lbs, BMI 20.4.
General: The patient seems to be well-behaved, alert, and oriented X4. She is anxious and distressed, but she sits upright. Her responses to queries were brief and logical, though she avoided eye contact throughout the conversation. She complained of headaches and sensitivity to light where she termed the conditions to be nagging.
HEENT: Head; normocephalic with an even and normal distribution of hairs on her head. She had a strong headache with a throbbing sensation in the right temporal region. Eyes; no sinus tenderness, conjunctivas and are PERRLA clear and sees an optician every four months. Ears; no pinna or tragus abnormalities, no tenderness or ear canal inflammation, bilateral cerumen, intact and pearly grey. Throat and Mouth; normal dental formation with milk-white teeth, gums are pink and free of sores or lesions and sees a dentist every four months.
Neck: Trachea midline, with no lymphadenopathy or carotid bruits noted. Mild Pain that radiates down her neck
Pulmonary: Lungs clear to auscultation with no rales or wheezes. upon breathing, chest walls rise and fall symmetrically. Negative for cardiac heave or lifts, and no distress was noted.
Cardiovascular: S1 and S2 are audible with a regular heart rate and rhythm when auscultated. No frictional rubs or gallops were noted.
Gastrointestinal: Nausea without vomiting, soft and round, no guarding or rebound tenderness was noted, normal bowel sounds present in all the four quadrants. No masses or tenderness upon palpation of the CVA region.
Genitourinary: Bladder is non distended. Negative for infections at the labia majora or at the perennial area. Moist perineal area with no lesions. Impalpable lymph nodes, and her vagina assumed a normal shape and size with regular pubic hairs.
Musculoskeletal: Full range of motion in all the extremities, negative for joint stiffness, enlarged joints, deformities or muscle cramps. warm to touch.
Neurologic/Psych: Patient is alert and oriented. Negative for sensory deformities. Speech was clear and logical backed by normal tone of an aging woman. negative for abnormal reflexes, intact cranial nerves.
· Eyes exam would also be significant to ascertain whether the patient has conditions that may lead to severe headaches such as eye strain or sensitivities to white light (Cash et al., 2017).
· Blood chemistry and urinalysis may be done to rule out other conditions that may lead to headaches such as diabetes, infections and thyroid complications (Cash et al., 2017).
ASSESSMENT
Differential Diagnoses
Differential Dx: Migraines (ICD-10-CM-G43.909) – Migraines are often described as severe headaches that trigger a throbbing pain or a pulsing sensation on one side of the head. The headaches are accompanied by nausea, vomiting, and aggravated sensitivities to light and sound, though the condition manifests in stages that include prodrome, aura, attack, and post-drome (Becker, 2017). Migraine attacks are severe since they may last for hours or days; hence they are a bother since they may impact a person’s daily routine of activities. The condition has no age discrimination since it affects patients of all ages (Becker, 2017). The patient presents with a throbbing headache that affects her temporal area of the head, and the headache rose in the past few days. The patient also portrays some signs and symptoms of the condition since she also stated having sensitivities to light and sound, as well as seizures.
Differential Dx: Cluster Headaches (ICD-10-CM-G44.009) – Cluster or cyclical headaches are severe since they occur in cyclical patterns. Cluster headaches wake a patient during the night with intense pain around one eye or one side of the head (Goadsby et al., 2018). The attacks may last between weeks and months, with remission periods when the headaches cease. In the remission sessions, the headaches tend to last between months and years. The headaches are rare, and they are not life-threatening. They manifest in the form of restlessness, pain in one side of the head or one eye, excessive tearing, redness of the eye on the affected side, pale skin, and runny nose (Goadsby et al., 2018). People with cluster headaches may also be affected by gazing. The differential will not be considered since the patient did not report a runny nose, swelling in the eye or redness in one eye, or dropping of an eyelid (Goadsby et al., 2018).
Differential Dx: Viral Meningitis (ICD-10-CM-A87.9) – Viral meningitis is a type of meningitis caused by viruses’ infections, and it is the most common. Non-polio enteroviruses primarily cause the condition though it can also be caused by mumps virus, measles virus, influenza virus, and herpes virus (Brouwer & Van de Beek, 2017). The condition manifests in irritations, poor appetite, lethargy, fever, headache, nausea, vomiting, sleeping troubles, photophobia, and stiff neck (Brouwer & Van de Beek, 2017). The differential will be disregarded since the patient did not report neck stiffness, vomiting, lethargy, fever, or a history of sexually transmitted infections such as herpes virus.
Final Differential: Migraines (ICD-10-CM-G43.909) – The patient is affected by migraine since the signs and symptoms she presented most correlate to signs and symptoms of migraines (Becker, 2017). She presented with a severe headache that was accompanied by throbbing pain in her temporal section of the head (Becker, 2017). The lab tests affirmed the diagnoses of migraines since the blood chemistry and urinalyses reflected no infections or the presence of other comorbidities such as diabetes and thyroid challenges. Imaging studies reflected that the patient was not suffering from head injuries or brain infections.
PLAN
DIAGNOSTIC LAB: The use of neuroimaging, CT, and MRI is depending on the patient’s medical history and physical examination.
Neuroimaging: If a patient has a severe headache, is over 40 years old, has start of headache with exertion, cough, or sexual activities, or has neurological impairment, neuroimaging should be considered (Cash et al., 2017). For an adult with a stable headache, no abnormal findings on examination, and no indication of seizure, neuroimaging will not be required (Cash et al., 2017).
Emergent CT- scan: When a patient complains of “the worst headache ever” and when focal neurological abnormalities, nuchal rigidity, or changed mental state are evident, an urgent CT scan without contrast should be obtained (Cash et al., 2017).
Laboratory test: Most patients with typical symptoms and a negative physical examination do not require a lab test. To rule out opioid and illicit substance abuse, a urine drug test may be recommended. CMP, CBC, TSH, and ESR are also recommended (Cash et al., 2017).
TREATMENT PLAN AND EDUCATION
The patient should be administered with Sumatriptan 50mg when the symptoms of migraines start, such as headaches, nausea, or vomiting (UpToDate, 2020). If the condition’s symptoms persist, the patient should take a second tablet of the dosage after two hours. When taking another dose, the patient should consult with a physician. In 24 hours, one should not take more than 200mg of Sumatriptan medication since it is an overdose that would result in adverse conditions (UpToDate, 2020). Sumatriptan drug belongs to the class of selective serotonin receptor agonists drugs, which is effective in the control of migraines in mild to severe states (UpToDate, 2020). NSAIDs and Acetaminophens may be used to control migraines in mild to moderate states. The drug should not be taken with other medics of the selective serotonin receptor agonists class.
Encourage the patient to keep a headache diary that is accurate and current at all times. This diary will assist the patient in identifying migraine headache triggers. (Cash et al., 2017). The patient should be counselled to monitor her sleeping patterns since they may have resulted in the rise of migraines. She should exercise ample rest time. The patient should also embark on decreased caffeine use and go back to her exercise practice (McLaren, 2021). The patient should also be counselled to reduce stress in her life and embark on a healthy diet plan which will enable her maximum nutritional value from her meals (McLaren, 2021). The patient should also stick by her medications for an effective therapeutic effect.
FOLLOW-UP: Schedule a follow-up in two weeks to evaluate treatment effectiveness and to revise with her headache diary.
Referral: Refer her to neurology if the meds don’t help her headache or send her to the emergency room if she has any neurological or life-threatening signs and symptoms. (Cash et at., 2017).
References
Becker, W. J. (2017). The diagnosis and management of chronic migraine in primary care. Headache: The Journal of Head and Face Pain, 57(9), 1471-1481. https://doi.org/10.1111/head.13089
Brouwer, M. C., & Van de Beek, D. (2017). Viral Meningitis: Epidemiology, diagnosis, and treatment of brain abscesses. Current Opinion in Infectious Diseases, 30(1), 129-134. https://doi.org/10.1097/qco.0000000000000334
Cash, J. C., Glass, C. A., & Mullen, J. (2017). Family practice guidelines (4th ed.). Springer Publishing Company.
Goadsby, P., Wei, D., & Yuan Ong, J. (2018). Cluster headache: Epidemiology, pathophysiology, clinical features, and diagnosis. Annals of Indian Academy of Neurology, 21(5), 3. https://doi.org/10.4103/aian.aian_349_17
McLaren, D. (2021). Headaches and migraines: Medication overuse headache-a difficult pill not to swallow. AJP: The Australian Journal of Pharmacy, 102(1206).
UpToDate. (2020). UpToDate. Retrieved December 3, 2021, from https://www.uptodate.com/contents/acute-treatment-of-migraine-in-adults
