A Comprehensive Analysis through Episodic/Focused SOAP Note
CASE STUDY:
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.
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 with APA references.
ATTACHED IS THE SOAP NOTE TEMPLATE TO USE: Episodic/Focused SOAP Note Template
Episodic/Focused SOAP Note
Patient Information:
Patient Initials: B.P. Gender: Male Age: 20 years Race: White
Subjective:
CC: “I have intermittent headaches which also radiate to the jaws, cheekbones, and the nose.”
HPI: B.P. is a 20-year-old male patient who has come to the hospital for the first time unaccompanied. According to B.P., he has been having intermittent headaches for the past one week. He feels the pain all over his head. However, he feels the intensity and pressure of the headache above the eyes. B.P. further indicates that the headache also scatters to the cheekbones, nose, and jaw.
Location: Head
Onset: One week
Character: A throbbing pain that is localized above the eyes and scatters all over the head.
Associated signs and symptoms: Headache that spread to the bones of the cheekbones, the jaws, and the nose.
Timing: Intermittent
Exacerbating/ relieving factors: Nothing has been found to exacerbate or relieve the headache.
Severity: 8/10 on the pain scale.
Current Medications: None.
Allergies: No known food or drug allergies reported.
Past Medical History: B.P.’s medical records indicate that he received all immunizations according to schedule. His last tetanus vaccine was two weeks ago when he had a wound on his right leg. B.P. denies previous hospitalizations or being diagnosed with a serious medical condition. He cannot remember whether he has ever been treated of common childhood diseases such as malaria and pneumonia.
Social History: B.P. loves football, cycling, and swimming. He goes swimming every weekend and likes to read novels during his free time. His father is an accountant and his mother is a nurse. Both of them are employed and they go to work in a nearby city every day. B.P. denies consuming cigarettes, alcohol, or illicit drugs.
Family History: Both maternal and paternal grandparents are still alive. Maternal grandmother has diabetes and his paternal grandfather has high blood pressure. B.P. does not know the ages of his grandparents. His mother, father, and two sisters are alive and they have not been diagnosed with a serious medical condition.
Review of Systems:
General: Denies fever, chills, or nausea.
HEENT: B.P. denies a history of physical head injury. However, he reports intermittent headaches which diffuse all over his head and scatter to the jaw, cheekbone, and nose. B.P. does not report any problems with hearing or vision. He does not report a runny nose. Reports a headache that spreads to the nose. Denies a sore throat.
Neck: Does not report pain in the neck region. Reports headaches that spread to the jaws and cheekbone.
Cardiovascular/Peripheral Vascular: Denies tightness of the chest. Does not report palpitations and denies chest pain.
Respiratory: B.P. denies chest congestion or breathing difficulties.
Gastrointestinal: Reports no abdominal pain, constipation, indigestion, abdominal swelling, or abnormal bowel movements.
Genitourinary: Report no abnormal urination frequency. B.P. denies changes in urine volume.
Neurological: Reports intermittent headaches which spread all over the head and radiate to the nose, cheekbones, and jaws. Denies numbness of fingers and toes. Does not report heat or cold intolerance.
Musculoskeletal: Does not report joint pain or movement/walking difficulties.
Skin: B.P. denies skin itchiness, redness, or rashes on the skin.
Psychiatric: B.P. does not report mental health problems and denies a history of anxiety, post-traumatic stress disorder, or depression.
Hematologic: Denies sickle cell disease. Denies a history of anemia or other blood disorders.
Endocrine: Does not report abnormal night sweats or thyroid issues.
Allergic/Immunologic: No known allergies reported.
Objective:
General: B.P. is oriented to time, place, and person. He is well groomed and attentive.
Vital Signs: BP 110/85, T 98.6F, weight 113 lb, heart rate: 92 beats per minute. Signs of fever observed
HEENT: Head is normocephalic. No evidence of physical injury. Conjunctiva is moist and eyes are sensitive to changes in light intensity. No evidence of ear blockage or injury. The nasal mucosa is hairy, pink, and moist. Throat is non-erythematous.
Neck: No evidence of neck pain.
Lungs: No wheezing sound heard. Both lungs contract comfortably during exhalation and expand comfortably during inhalation.
Heart/Cardiovascular: No heart murmurs, no gallop.
Abdomen: No masses, abdominal tenderness, or distention.
Musculoskeletal: No evidence of joint pain.
Neurological: Pain in the cheekbone and jaws is rated as 8/10 on the pain scale.
Skin: Skin is smooth, warm, hairy, and without lesions.
Diagnostic tests:
- Computed tomography (CT) scan of the head: To generate images of head structures (Evans et al., 2020).
- Sinus x-ray: To determine involvement of sinus infections (Straburzyński et al., 2021).
- Magnetic resonance imaging (MRI) of the head: To obtain more detailed images of the head structured when compared with those obtained from a CT scan (Evans et al., 2020).
- Urinalysis and blood chemistry: To either rule out or confirm the presence of other medical conditions such as diabetes (Tanha et al., 2021).
A.
Primary diagnosis: Tension-type headache
Differential diagnoses:
- Tension-type headache (primary diagnosis): Characterized by headaches that diffuse around the head and which usually radiate to other nearby muscles (Ashina et al., 2021).
- Primary stabbing headache: Headaches that concentrate on the head. Common in children and adolescents. My also spread to other regions around the head (Takeshita et al., 2021).
- Cluster-type headache: Usually concentrated on one side of the head. Rarely radiates to other regions around the head (Suri & Ailani, 2021).
- Migraine: Usually concentrated on one side of the head. Patients may also present with weakness and nausea (Evans et al., 2020).
- Paroxysmal hemicranias: Usually characterized by a throbbing and claw-like pain. Normally radiates to the back of affected individuals (Paliwal & Uniyal, 2021).
References
Ashina, S., Mitsikostas, D. D., Lee, M. J., Yamani, N., Wang, S. J., Messina, R., Ashina, H., Buse, D. C., Pozo-Rosich, P., Jensen, R. H., Diener, H. C., & Lipton, R. B. (2021). Tension-type headache. Nature Reviews Disease Primers, 7(1):24. https://doi.org/10.1038/s41572-021-00257-2. PMID: 33767185.
Evans, R. W., Burch, R. C., Frishberg, B. M., Marmura, M. J., Mechtler, L. L., Silberstein, S. D., & Turner, D. P. (2020). Neuroimaging for migraine: The American Headache Society Systematic Review and Evidence-Based Guideline. Headache, 60(2):318-336. https://doi.org/10.1111/head.13720. Epub 2019 Dec 31. PMID: 31891197.
Paliwal, V. K. & Uniyal, R. (2021). Paroxysmal hemicrania: An update. Neurology India, 69(Supplement), S135-S143. https://doi.org/10.4103/0028-3886.315982. PMID: 34003159.
Straburzyński, M., Gryglas-Dworak, A., Nowaczewska, M., Brożek-Mądry, E., & Martelletti, P. (2021). Etiology of ‘sinus headache’-moving the focus from rhinology to neurology. a systematic review. Brain Sciences, 11(1), 79. https://doi.org/10.3390/brainsci11010079
Suri, H. & Ailani, J. (2021). Cluster headache: A review and update in treatment. Current Neurology and Neuroscience Reports, 21(7):31. https://doi.org/10.1007/s11910-021-01114-1. PMID: 33948734.
Takeshita, M., Ishida, Y., Kano, K., Go, S., Morichi, S., Morishita, N, Suzuki, S., Takamatsu, T., Watanabe, Y., Oana, S., Kawashima, H., & Yamanaka, G. (2021). Primary stabbing headache in children and adolescents. Indian Journal of Pediatrics, 88(11):1160. https://doi.org/10.1007/s12098-021-03889-0. Epub 2021 Aug 11. PMID: 34379299.
Tanha, H. M., Martin, N. G., Whitfield, J. B., & Nyholt, D. R. (2021). International Headache Genetics Consortium (IHGC). Association and genetic overlap between clinical chemistry tests and migraine. Cephalalgia, 41(11-12):1208-1221. https://doi.org/10.1177/03331024211018131. Epub 2021 Jun 15. PMID: 34130515.