NURS 6512 Week 9 Case 1: Episodic/Focused SOAP Note
NURS 6512 Week 9 Case 1: Episodic/Focused SOAP Note
CASE STUDY 1: Headaches 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.
L/M/N/O/P/Q/R/S/T/U/V/W/X/Y/Z
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To Prepare
Your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
With regard to the case study you were assigned:
Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study you were assigned.
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?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
This is due day 6 of week 9
To Prepare
By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
With regard to the case study you were assigned:
Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study you were assigned.
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?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
The Case Study 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 in the Week 5 resources. Provide evidence from the 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.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 7, “Mental Status”
This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms.
·Chapter 23, “Neurologic System”
The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 4, “Affective Changes”
This chapter outlines how to identify the potential cause of affective changes in a patient. The authors provide a suggested approach to the evaluation of this type of change, and they include specific tools that can be used as part of the diagnosis.
Chapter 9, “Confusion in Older Adults”
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Episodic/Focused SOAP Note Template
Patient Information:
Initials: R. H Age: 20yo Sex: Male Race: N/A
SUBJECTIVE DATA
CC: “I have been experiencing intermittent headaches.”
HPI: CASE STUDY 1: The client, R. H, is a 20yo male with complaints of intermittent headaches. The client reported that the headaches spread all over the head. However, she experiences the most significant pressure and intensity above the eyes, which spreads to the nose, jaw, and cheekbones.
Location: Head
Onset: No specified
Character: Intermittent headaches that spread all over the head. The most significant pressure and intensity occur above the eyes and then spreads to the nose, jaw, and cheekbones.
Associated signs and symptoms: No associated symptoms.
Timing: Not indicated
Exacerbating/ relieving factors: Not indicated
Severity: Not specified
Current Medications: Not under any medication.
Allergies: No food, drug, or environmental allergies.
PMH: Denies past chronic illnesses or surgeries.
Soc Hx: The client is a first-born in a family of four. He is a social drinker and takes three bottles of beer when he goes out with friends over the weekend. Takes one glass of coffee daily. He denies smoking cigarettes or using other illegal drugs.
Fam Hx: His father and mother are alive at 48 and 53 years, respectively. Both his parents and three siblings have no known health condition.
ROS:
GENERAL: Denies weight changes.
HEENT: He reports a headache. Denies double vision. Denies hearing loss. Denies nasal congestion. Denies sore throat.
SKIN: Denies itching.
CARDIOVASCULAR: Denies chest discomfort.
RESPIRATORY: Denies sputum production.
GASTROINTESTINAL: Denies diarrhea or constipation.
GENITOURINARY: Denies pain with urination.
NEUROLOGICAL: Denies numbness.
MUSCULOSKELETAL: Denies joint pain or muscle stiffness.
HEMATOLOGIC: Denies bruising.
LYMPHATICS: Denies splenectomy history.
PSYCHIATRIC: Denies anxiety.
ENDOCRINOLOGIC: Denies polyuria.
ALLERGIES: Denies drug allergy.
OBJECTIVE DATA
Physical exam:
Vital signs: PR-87, RR-20, BP- 140/89 mmHg, Temp- 98.3, SpO2-96.7%, Ht- 5’8,” and Wt- 175 lbs.
General: The client is well groomed and looks younger than his age. Maintains eye contact and is cooperative. He is alert and oriented to persons, places, events, times, and situations.
HEENT: Head: Normocephalic head with no swellings. Eyes have clear conjunctiva. Ears have a normal external auditory canal. Pink and moist nasal mucous membranes. Pink and moist oral mucous membrane.
Neck: Has no swellings or scars.
Musculoskeletal: No joint swelling.
Skin: No pigmentation or rashes.
Cardiovascular: S1 and S2 present with no abnormal sound.
Respiratory: Normal breath sounds.
Gastrointestinal: Tender and soft with no swellings.
Genitourinary: No suprapubic tenderness.
Neurological: Intact cranial nerves.
Diagnostics
Neurological examination
ASSESSMENT
Differential Diagnoses
Potential diagnoses for this client are listed below, starting from the most likely diagnosis.
- Sinus headache
- Migraine headache
- Cluster headache
- Tension headache
- Idiopathic stabbing headache
Sinus headache- This condition is characterized headache that feels like pressure around the eyes, forehead, and cheeks (Jang et al., 2022). The client reported the greatest pressure and intensity above the eyes, which spreads to the nose, jaw, and cheekbones. Thus, sinus headache qualifies as the primary diagnosis.
Migraine headache: This condition is characterized by severe headaches on and off (Kim & Patel, 2020). The client might have this condition since she reported intermittent headaches. However, it is ruled out since it is not characterized by pressure over the eyes.
Cluster headache: This condition is characterized by excruciating pain around one eye but may spread to the head, face, and neck (Wei et al., 2018). The client qualifies for this diagnosis since she reported a headache. However, it was ruled out since pain originated in the head.
Tension headache: This type of headache is characterized by dull and aching head pain and pressure or tightness across the forehead, back, or sides. The client reported pain in the head, qualifying for this diagnosis. However, this condition was ruled out because the pain spread to the back or sides.
Idiopathic stabbing headache is a brief but severe jabbing pain occurring in any part of the head (Kim et al., 2017). The client qualifies for this condition since she reported pain in the head. Nonetheless, it was ruled out since it was not severe and jabbing.
References
Jang, D. W., Godley, F. A., & Hachem, R. A. (2022). Sinus headache: changing the treatment paradigm. Current Opinion in Otolaryngology & Head and Neck Surgery, 30(1), 63-67. https://www.binasss.sa.cr/mar22/38.pdf
Kim, D. Y., Lee, M. J., Choi, H. A., Choi, H., & Chung, C. S. (2017). Clinical patterns of primary stabbing headache: a single clinic-based prospective study. The Journal of Headache and Pain, 18(1), 1-9. Doi: 10.1186/s10194-017-0749-7
Kim, R., & Patel, Z. M. (2020). Sinus headache: differential diagnosis and an evidence-based approach. Otolaryngologic Clinics of North America, 53(5), 897-904. https://doi.org/10.1016/j.otc.2020.05.019
Wei, D. Y. T., Ong, J. J. Y., & Goadsby, P. J. (2018). Cluster headache: epidemiology, pathophysiology, clinical features, and diagnosis. Annals of Indian Academy of Neurology, 21(Suppl 1), S3. Doi: 10.4103/aian.AIAN_349_17