Assignment 1: Week 9 Episodic/Focused SOAP Note
Assignment 1: Week 9 Episodic/Focused SOAP Note
Patient Information:
Ms. X.Y., 40 years old Female.
S.
CC (chief complaint): “I have been experiencing some headaches for the past one week. I had also experienced a ‘heat cold’ three weeks ago, which I thought was getting better. However, the sinus symptoms are back and even worse.”
HPI: Ms. X.Y. is a 40-year-old female patient who has presented for evaluation with complaints of headaches for one week. She reported experiencing a “heat cold” three weeks ago and thought it would improve, but to her surprise, the sinus symptoms have recurred and are even worse. She describes the headache as localized to her forehead, and she feels like there is pressure behind her eyes, and she cannot breathe out of her nose. She reports a feeling of mucus trickling at the back of her throat. She says the pain is sometimes severe (8/10), but acetaminophen reduces it to moderate (4/10), and sometimes it is only mild (2/10). She reports experiencing an occasional cough, and sometimes she feels feverish, with frequent sneezing and poor appetite. She reports that the headache is worsened by bending over. She says acetaminophen only improves her headache but does not alleviate it completely. She admits taking Sudafed HCL 120mg every 12 hours, with some relief. She describes her symptoms as worse in the morning, and she wakes up with a headache. The range is between 2/10 to 8/10. She reports that the headache is making her have problems concentrating at her job, and she is so fatigued.
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Location: Forehead.
Onset: One week.
Character: Throbbing.
Associated signs and symptoms: Pressure behind eyes, unable to breathe out of nose, postnasal drip, fever, and reduced appetite.
Timing: Worse in the morning.
Exacerbating/ relieving factors: Aggravated by bending over, relieved by acetaminophen.
Severity: Ranges from mild (2/10) to severe (8/10)
Current Medications: Acetaminophen 500 mg P.O. TDS, Sudafed HCL 120 mg 12 hourly
Allergies: None
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PMHx: No history of chronic illness or hospital admission. Influenza vaccine received in 2020, has had a tetanus vaccine, received all childhood vaccines as recommended.
Soc Hx: No history of smoking or alcohol intake.
Fam Hx: She is married, sexually active, and they have three children. No family history of asthma or cancer.
ROS:
GENERAL: Positive for fever. No weight loss or drenching night sweats.
HEENT: Reports pain behind her eyes, inability to breathe out of nose, postnasal drip, and sneezing. She denies epistaxis, hearing loss, tinnitus, or loss of sight.
SKIN: No rashes.
CARDIOVASCULAR: Denies chest pain or awareness of heartbeat.
RESPIRATORY: Denies cough, dyspnea, or wheezing.
GASTROINTESTINAL: Endorses appetite loss.
GENITOURINARY: No frequency, dysuria, or hematuria.
NEUROLOGICAL: Headache.
MUSCULOSKELETAL: No muscle, joint, or bone pain.
HEMATOLOGIC: No bleeding tendencies or anemia.
LYMPHATICS: No enlarged lymph nodes.
PSYCHIATRIC: No depression, anxiety, or hallucinations.
ENDOCRINOLOGIC: No polyuria, polyphagia, polydipsia, or heat/cold intolerance.
ALLERGIES: None.
O.
Physical exam:
Vital Signs: Blood pressure 128/74mmHg, heart rate 78, respiratory rate 18, temperature 37.2
General: Oriented ×3
HEENT: Normocephalic head, normal ear, and eye anatomy. Patent nostrils, no tonsillar enlargement, inflamed oropharynx.
Neck: No lymph node enlargement
Chest/Lungs: Symmetrical movement on respiration, equal chest expansion, and bilateral air entry. No wheeze or crackle on auscultation.
Heart/Peripheral Vascular: Normoactive precordium, S1, and S2 heart sounds heard. Both proximal and distal pulses are palpated, present, and adequate.
Abdomen: Normal fullness, moves with respiration, bowel sounds auscultated.
Genital/Rectal: Not done.
Musculoskeletal: Normal ranges of motion.
Skin: No hypo/hyperpigmentation.
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Diagnostic results:
Approaching a neurology patient requires comprehensive history taking and physical examination to make a diagnosis. More often, the diagnosis is clinical. However, some tests may be necessary to be conducted and may supplement the information with which a diagnosis will be made.
Complete blood count (CBC): This is a baseline investigation to check for signs of infection demonstrated by leukocytosis and to check for hemoglobin status.
C.T. scan of the head: This will be done to rule out any space-occupying lesion which would be causing the headaches (Özdemir & M Das, 2021). Also, the sinuses can be evaluated if inflamed and causing the headache and other associated symptoms.
A.
Differential Diagnoses
Sinus Headache (Primary Diagnosis)
It is caused by sinusitis. Sinusitis refers to the inflammation of the sinuses due to bacterial or viral infections (Kim & Patel, 2020). In sinusitis, the sinuses undergo inflammation, increased blood flow, pressure changes, and irritation of the cranial nerves (DeBoer & Kwon, 2022). Pain is due to inflammatory processes and congestion that cause an increase in sinus pressure. Irritation of the nerves results in pain and discomfort. With increased blood flow, vessel dilatation results in pressure sensation and discomfort (DeBoer & Kwon, 2022). Patients will present with purulent nasal discharge, facial pressure/pain, and nasal obstruction. Almost all the patients report a history of headaches. Other associated symptoms of a sinus headache include cough, body malaise, hyposmia/anosmia, dental pain, and ear fullness (DeBoer & Kwon, 2022). Signs and symptoms of a sinus headache include pain, facial pressure, and a sensation of fullness in the forehead, and the pain is worsened when the patient lies down or bends forward. Other reported symptoms include excessive fatigue, stuffy nose, and aching sensation localized to the upper tooth.
This is the most appropriate diagnosis for the patient. She reported a heat cold three weeks ago, which was the initial stage of sinus infection; she reported worsening sinus symptoms. Her presenting features are typical with this diagnosis as she has a headache localized to the forehead, pressure behind her eyes, and difficulty breathing with her nose. Other supporting features include a postnasal drip, non-productive cough, fever, and headache worsened by bending forward.
Migraine Headache
Migraine is a primary headache syndrome associated with unilateral moderate to severe episodes characterized by nausea, photophobia, and phonophobia (Eigenbrodt et al., 2021). The headache is described as pulsatile, unilateral, throbbing in nature, and increasing in intensity. Pescador Ruschel & De Jesus (2020) describes its localization as frontotemporal, and the pain can last over hours to days, typically 4-72 hours, with associated vomiting, phonophobia, and photophobia. Nasal symptoms associated with migraine headaches include facial fullness, congestion, and watery nasal discharge, because of the involvement of the autonomic nervous system during migraine attacks. Several patients report an aura where they experience tinnitus, bright lines or shapes, noises, rhythmic movements, and paresthesia (Pescador Ruschel & De Jesus, 2020). Lack of aura preceding this headache rules out migraine headache as the primary diagnosis. Additionally, there is no associated vomiting, photophobia, or phonophobia.
Tension-type Headache
This is a primary headache syndrome where patients experience dull and tight pain with a sensation of a band tied around the head or pressure around the vertex region (Shah & Hameed, 2020). There is reported bifrontal, nuchal, occipital, and holo-cranial tightness. Patient report of constant and generalized pain that may radiate anteriorly from the occiput (Shah & Hameed, 2020). In most cases, the patient looks stable, at the pain rarely disables them. The headache may be episodic or persistent. There are no reports of vomiting, or photophobia, unless if severe. It is precipitated by sitting for long, stress, poor sleeping postures, and neck strain (Shah & Hameed, 2020). It is a close differential for this patient, but it does not qualify as the primary diagnosis since it is not associated with sinus symptoms, as demonstrated by the patient.
Chronic Paroxysmal Hemicrania
It is an uncommon headache type where patients have severe unilateral pain localized to the eyes, with associated tearing, nasal congestion, redness, and swelling (Bodle & Emmady, 2020). The headache is sharp and stabbing, and the frequency of occurrence is more than five times a day. It is associated with cranial autonomic features such as aural fullness, diaphoresis, miosis, and facial flushing (Bodle & Emmady, 2020). The exact etiology is not understood, but it has been linked with head and neck trauma in cases where it has been diagnosed. This is a close differential but not likely for the patient in the case.
Cluster Headaches
This primary headache syndrome is associated with unilateral pain localized to the eyes or temple (Kandel & Mandiga, 2020). The onset is insidious, and the maximum intensity develops over minutes. The pain is deep, constant, excruciating, and explosive. Associated symptoms of cluster headaches include rhinorrhea, nasal congestion, restlessness, diaphoresis, ipsilateral tearing, and redness of the eyes (Kandel & Mandiga, 2020). Patients report being awakened at night in more than 50% of the attacks. Not likely as the primary diagnosis as the pain is unilateral in this case.
References
Bodle, J., & Emmady, P. D. (2020). Chronic Paroxysmal Hemicrania. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK558980/
DeBoer, D. L., & Kwon, E. (2022, August 8). Acute Sinusitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK547701/
Eigenbrodt, A. K., Ashina, H., Khan, S., Diener, H.-C., Mitsikostas, D. D., Sinclair, A. J., Pozo-Rosich, P., Martelletti, P., Ducros, A., Lantéri-Minet, M., Braschinsky, M., del Rio, M. S., Daniel, O., Özge, A., Mammadbayli, A., Arons, M., Skorobogatykh, K., Romanenko, V., Terwindt, G. M., & Paemeleire, K. (2021). Diagnosis and management of migraine in ten steps. Nature Reviews Neurology, 17, 1–14. https://doi.org/10.1038/s41582-021-00509-5
Kandel, S. A., & Mandiga, P. (2020). Cluster Headache. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK544241/
Kim, R., & Patel, Z. M. (2020). Sinus Headache. Otolaryngologic Clinics of North America, 53(5), 897–904. https://doi.org/10.1016/j.otc.2020.05.019
Özdemir, M., & M Das, J. (2021). Skull Imaging. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556122/
Pescador Ruschel, M. A., & De Jesus, O. (2020). Migraine Headache. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560787/
Shah, N., & Hameed, S. (2020). Muscle Contraction Tension Headache. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK562274/
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Create an episodic/focused note in SOAP format about the case study below. Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.
Continue documentation of focused/Episodic SOAP notes. In a Focus SOAP note, include an assessment of the General, Heart, Lungs, and Affected systems. In the Affected system, provide a detailed assessment based on what you expect to see, hear, and feel, based on your diagnosis. In completing your SOAP note, consider what history you need to gather from the patient. In the objective section, include findings from your Physical exam, based on the patient’s diagnosis. Refer to Chapter 2 of the Sullivan Text and the Episodic Template in Week 5 Learning Resources for Guidance.
You will need to make up information to complete the focus note.
List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Case Study: Headaches
A 40-year-old female presents with a complaint of a headache for one week. Reports a “head cold” 3 weeks ago. Thought it was getting better, but sinus symptoms are back and even worse.
Describes the headache is located across her forehead; feels like pressure behind my eyes and unable to breathe out of nose. Also feels mucus running down the back of throat. Pain sometimes severe (8/10) but with acetaminophen reduces to moderate (4/10) and occasionally mild (2/10). Occasional nonproductive cough. Feels feverish at times; noted frequent sneezing and no appetite. Bending over seems to make the headache worse. “Acetaminophen improves my headache but doesn’t take it away.” Taking Sudafed HCL 120 mg every 12 hours, with some relief. Symptoms are worse in the morning – awakes with a headache. Ranges from 2/10 at its best to 8/10. Difficulty with concentrating at job and feels very tired.
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.
NURS_6512_Week_9_Assignment1_Rubric
| NURS_6512_Week_9_Assignment1_Rubric | ||||||
| Criteria | Ratings | Pts | ||||
| This criterion is linked to a Learning OutcomeUsing 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 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 pts | ||||
| This criterion is linked to a Learning OutcomeWritten 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 pts | ||||
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
|
5 pts | ||||
| This criterion is linked to a Learning OutcomeWritten 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 pts | ||||
| Total Points: 100 | ||||||