SOAP Note- Evaluation of a Primary Care Patient with Persistent Headaches

Consent: An informed consent was sought from the patient before beginning the assessment. He was also notified that the neurological exam section would be recorded and the video uploaded to YouTube for educative purposes. most

SUBJECTIVE

ID: The case is of a 28-year-old Filipino male, ADM. He is reliable and the primary source of his medical and medication information. He came to the clinic alone.

CC: “I have a strong headache on the right side of my forehead and around my right ear”.

HPI: ADM is a 28-year-old Filipino male presenting with complaints of a unilateral headache. The headaches have been on and off since he was 25 years of age. They can manifest once or twice a month but sometimes appear more than twice a month. They typically occur on the right side of the head and may last a few minutes to hours. The headache is of throbbing type and is aggravated by activity and relieved by rest. He reports that a scintillating scotoma precedes his headaches and may last for about half an hour. Additionally, he sometimes feels tired, becomes light and sound sensitive, and sweats a lot whenever he is about to experience headaches. He added that he usually feels dizzy after the headaches are gone.

PMH: He denies having had any medical issues before. He, however, reported that he has been battling frequent headaches over the past few years and has been managing them through rest and over-the-counter medications.

Surgeries and hospitalizations: ADM has never been hospitalized before. He has neither been involved in an accident nor had any surgeries or head injuries.
Immunizations: ADM is up to date with vaccinations, including the annual flu vaccine and the COVID-19 vaccinations.
Allergies: He is allergic to pollen and animal dander.
Medications: He is currently taking Tylenol 1g and Advil 400mg every 8 hours.

Family Hx

His mother is allergic to pollen. His father and elder brother have been diagnosed with migraine headaches and have been on medications. He denies having a close family member with any chronic illness.

Chemicals: ADM is a social drinker. He takes wine and smokes at social events. He denies having ever taken any illicit substances.

Diet/exercise/caffeine: ADM tries to stick to a healthy diet. He eats a lot of fruits, restricts his carbohydrate intake, exercises mildly after work, and takes caffeine regularly.

Sexual/Reproductive History: ADM identifies as a male and is sexually active. He engages in a monogamous relationship and indulges in protected sex. He denies having ever contracted any sexually transmitted infection.

Social History

Occupation/marital/relationship/military status & current living situation: ADM works as a hotel attendant. He currently lives alone but is in a relationship. He denies having served in the military. He lives in a rental space in a safe neighborhood.
Spiritual/Social Supports: ADM is a staunch catholic. He subscribes to Christian values and believes in divine healing. He turns to prayers whenever he is ill and believes that a combination of prayers and medications is what has been keeping him going. His source of social support is his family. He contacts them frequently and notifies them of his well-being.
Safety: Helmets, seatbelts, texting/drinking, and driving, does the patient own guns?ADM reports using seat belts and helmets whenever he is driving or skating. He denied texting or using a phone while driving. He does not own a gun.

Review of Systems

CONSTITUTIONAL: No reports of fever, weight loss, chills, or fatigue.
EYES : Vision is intact. No reports of visual loss, eye discharge, double vision, or blurriness. There were also no reports of recent eye injuries or infection. There were, however, reports of blurriness and scintillation before headache episodes.
EN T: No reports of tinnitus, hearing loss, ear infections, or ear discharge. There were also no reports of nasal discharge, tenderness or swelling, and loss of smell functionalities. The patient denied having any difficulty swallowing, pain during swallowing, or sore throat.
CVS: No reports of palpitation, chest discomfort, and edema.
RESP: No reports of shortness of breath, difficulties in breathing, wheezing, coughing, sneezing, or excess mucus production.
GI: Denies any inconsistencies in his bowel movement, bowel distension, or tenderness.
GU :No reports of dysuria, urinary frequency, hesitancy, and urgency. The patient also denied having had any malodorous urine or abnormal urinary color change.
MSK: Denies any muscle stiffness, muscle pain, tenderness, or limitations in joint movements.
SKIN/BREAST: Denies skin lesions, scars, swelling, tenderness, or abnormal skin color changes. Also denies any lesions, tenderness, or abnormal swelling in either breast.
PSYCH: No reports of depression, anxiety, or any other mental health illnesses.
HEMA/LYMPHATIC: No reports of splenectomy, bruising, anemia, abnormal bleeding, or lymph node swelling.
END O: Denies any significant shift in his heat and cold sensitivity, diabetes, hair loss, sporadic energy shits, or sudden weight changes.
NEURO: He denies having experienced any syncope, or dizziness. There were also no reports of tremors, ataxia, or loss of control of bowel and genitourinary functionalities.

OBJECTIVE

Vital Signs

Physical Examination

General survey: The patient is cooperative and appears alert and oriented to place and event. No signs of fatigue, weight loss, fever or chills.
HEENT:The head is well-rounded with no depressions or swelling. The scalp is normal, with no hair loss, hair, or thickness identified. The eyes are symmetrical. No eye discharge was seen. The ears are symmetrical and soft to the touch. No signs of ear discharge, swelling, tenderness, or loss of earing. The color around the ear was also consistent with that on the face. The nose is midline on the face. No signs of deviations, nasal discharge, or tenderness. There were also no signs of oral thrush.
Neck: There were no signs of swelling, masses, or tenderness in the neck region. The color around the neck was also consistent with other areas of the body. There are no reports of pain or discomfort when flexing, extending, or rotating the neck. The trachea is midline on the neck. The patient denied experiencing any difficulty swallowing when asked to swallow.
CVS:The heart rate was normal, as revealed by the vital signs. The carotid upstroke was normal, with no bruits felt on auscultation. There were no signs of jugular vein distension. The jugular venous pressure was measured at 8cm when the patient assumed a supinated position and the head elevated at 30 degrees.
Resp: The chest was symmetrical with no signs of chest deformity, breathing distress, or use of accessory musculature while breathing. There was also no wheezing, respiratory crackles, or pericardial friction rub. No chest masses, tenderness, or pain was felt on deep and light palpation.
Abdomen/GI: The abdomen was well-rounded. Bowel movement sounds were felt in all of the four quadrants. There were no signs of tenderness, abdominal masses or pain, and abdominal distension.
GU: There were no signs of pelvic tenderness or pain.
M/S: There were no signs of joint swelling, tenderness, or muscular stiffness. There were also no signs of muscle pain or restricted range of motion in all the joints.
Hematologic and Lymph: There were no signs of lymphatic swelling or splenomegaly.
Skin:The skin was well hydrated. There were no signs of skin lesions, scarring, rashes, or color inconsistencies.
Extremities: There were no signs of finger clubbing, cyanosis, or edema. The peripheral pulses in the femoral, anterior tibialis, radial, brachial, popliteal, and dorsalis pedis areas were felt.

Neurological Examination and Cranial Nerves

Cognition: The patient is alert and responsive. He can follow three-stepped contralateral localizations, as demonstrated by his ability to touch his right nose using his left hand with his right hand raised. He is also fully aware of his surroundings.
Orientation: The patient is fully aware of his surroundings. When asked about where he was and what was going on, he noted that he was in a clinic for the management of a debilitating headache. He is also dressed appropriately for the event, time, and weather.
Speech: The patient has a normative speech. His speech is goal-directed, logical, and clear. No signs of slurred speech.
Memory and reasoning: His memory is normal, and his thought process is intact. He has a recall of events in the last five minutes of the interview and can recall past events. His reasoning is also logical.

Cranial Nerves

Cranial Nerve I (Olfactory): ADM can detect a strawberry smell when one of his nostrils is blocked using his right index finger, and his eyes are closed.
CN II (Optic): Snellen chart at 6m revealed a visual acuity of 20/20 for both eyes. Pupillary response to confrontation with light was noted on each eye separately. Peripheral vision was intact. Fundoscopic findings for both eyes revealed a normal fundus with a pale pink disc, 15mm diameter, and flat margins. With the patient seated across the examiner, covering the right eye using the right hand and vice versa, and directly gazing at the examiner, who is also doing the same, he reported no blind spots or double visions.
CN III (Oculomotor): With the patient gazing at a pen placed 35 cm in front of him and the pen moved in medial, lateral, and downward directions, the patient followed the target with his eyes without moving the head. The direct pupilar reflex response was noted as demonstrated by pupilar constriction when both eyes were shone with light independently. The consensual pupillary reflex response was also noted, as demonstrated by pupillary constriction in both eyes when light was directed to the left eye and vice versa. When shifting from an upright position to the supine position with the head tilted 45 degrees to the right, there was a bilateral gaze with no signs of nystagmus.
CNIV (Trochlear): With the patient gazing at a pen placed 35 cm in front of him and the pen moved in a medial and downward direction, the patient followed the target with his eyes without moving his head.
CNV (Trigeminal): The facial sensation was intact upon pinpicking the forehead, jaws, and cheeks. The patient held open his jaw for 10 seconds three times.
CNVI: (Abducenss): With the patient gazing at a pen placed 35 cm in front and the pen moved laterally, the patient followed the target with his eyes without moving the head.
CNVII (Facial): No wrinkling or hemifacial weakness was noted when the patient smiled or during the conversation.
CNVIII (Acoustic): The patient was able to repeat all of the words whispered to both of his ears during the Whisper Test. The Weber test revealed no lateralization of the vibrating tuning fork sound. The tuning sound was heard loudest when close to the auditory meatus and least when placed over the mastoid test, revealing a normal Rinne test.
CNIX and CNX (Glossopharyngeal and Vagus): There was a symmetric elevation of the uvula when the patient verbalized the “Aaah” sound.
CNXI (Spinal accessory): With the examiner’s hand pressing against the head of the patient, the patient was able to move the head against resistance. He moved his shoulders against resistance placed by the examiner.
CNXII (Hypoglossal): The tongue was midline on inspection. There were no signs of atrophy, loss of strength, or fasciculations on inspection of the tongue. It was also able to move laterally.

Cerebellum

Balance: The patient had a normal gait. The tandem walk test revealed that he could walk ten consecutive steps in a straight line in a heel-to-toe manner with his eyes open. The walk-on-heel tests revealed that he could walk on his heels for 15 feet. The walk-on-toe test revealed that ADM could walk on his toes for four consecutive steps. The patient maintained an upright position for 30 seconds with the eyes closed, and arms stretched outwards at 90 degrees with pronated arms, with no pronator deviation noted. The Romberg tests revealed that the patient could maintain an upright position after 60 seconds of closing his eyes. The rapid alternating actions were rhythmic and smooth as the patient could turn their hands rapidly.
Sensory: The patient could determine the joint position sense while maintaining a closed eye. He could also discern two nearby objects on his skin at distinct points and interpret symbols written on his skin while maintaining a closed eye. The patient could discern and detect cotton ball rub, pinprick, and vibrations on his upper and lower extremities.
Motor System: The patient could resist pressure on his deltoids, triceps, and biceps. The resistance was noted bilaterally. His hand grip and finger strength were also excellent. Excellent muscle tone and strength were noted bilaterally on his quads, hamstrings, hips, abductors, and adductors, as demonstrated by his ability to squat.
Reflexes: Bilateral deep tendon reflexes were not on the biceps, triceps, patellar, and Achilles. No signs of babinski reflex on firmly stroking the sole of both feet.

DIFFERENTIAL DIAGNOSIS

Migraine Headache with Aura ICD 10 Code G43.1

Migraine headaches are complex disorders characterized by episodic moderate to severe headaches. The headaches are often pulsating, unilateral, and last a few minutes to hours. The common triggers of migraine headaches are stress, some foods, hormonal changes, and alcohol ingestion, among others. In the prodrome phase of migraines, the patient may experience fatigue, craving, light and sound sensitivity, and sweating, among others. In migraine with aura, the aura phenomenon precedes the headaches. Aura is characterized by symptoms such as scintillating scotomas, tinnitus, paresthesias, and loss of language, memory, and motion, among others (Viana et al., 2019). The patient in the case presented presented with symptoms consistent with those of migraine with aura. This warrants the inclusion of this differential.

Migraine Headache without Aura ICD 10 Code G43.009

Migraine without aura often manifests with symptoms similar to those of migraine with aura except for the aura. In this type of migraine, an episodic pulsating headache becomes apparent. Additionally, the prodrome phase may also be apparent. The patient, in this case, presented with a pulsating headache. He also manifested symptoms similar to those seen in the prodrome phase of migraines, warranting the inclusion of this differential. It was, however, ruled out due to the presence of aura in the case presented.

Cluster Headache ICD 10 Code G44.009

Cluster headaches are short-lasting unilateral headaches. They are accompanied by one or more autonomic symptoms such as lacrimation, aural fullness, nasal congestion, and conjunctival infection (Ray et al., 2022). This differential was included because of the presence of a unilateral headache, as evident in the patient case presented. It was, however, ruled out due to the absence of autonomic symptoms.

PLAN

Neuroimaging, using a CT scan of a potential brain pathology.
Cerebrospinal fluid analysis to rule out meningococcal infections.
Treatment

Diagnostic Impression: Migraine with aura ICD 10 Code G43.1 The symptoms manifested by the patient in the case are consistent with those of migraine with aura. Neuroimaging results ruled out the potential for brain pathology.

Treatment

The patient will be started on Ibuprofen 400mg every 8 hours for 10 days and Zolmitriptan 10 mg every 24 hours for 10 days. Ibuprofen is an NSAID and is effective in managing mild to moderate pain. It is used in the abortive phase of managing migraine headaches. Triptans, such as zolmitriptan, are also effective in managing migraine. They are the first line in patients with allodynia (Aguilar-Shea et al., 2022). Other medications that can be used include ergots, such as ergotamine, and calcitonin gene-regulated peptide antagonists such as Rimegepant.

Education

The patient is advised to take his medications as directed for optimal clinical outcomes. He will also be educated on the disease process and the potential side effects of the prescribed medications. Ibuprofen is an NSAID with the potential to cause gastric irritation and subsequent PUD. Triptans can also cause jaw tightness, pain and pressure on the cheek, and skin irritations. Patients should report to the clinic whenever they experience these side effects.

Follow-up: The patient is scheduled to return to the clinic after one week of therapy.

References

Aguilar-Shea, A. L., Membrilla MD, J. A., & Diaz-de-Teran, J. (2022). Migraine review for general practice. Atención Primaria, 54(2), 102208. https://doi.org/10.1016/j.aprim.2021.102208

Ray, J. C., Stark, R. J., & Hutton, E. J. (2022). Cluster headache in adults. Australian Prescriber, 45(1), 15–20. https://doi.org/10.18773/austprescr.2022.004

Viana, M., Tronvik, E. A., Do, T. P., Zecca, C., & Hougaard, A. (2019). Clinical features of visual migraine aura: A systematic review. The Journal of Headache and Pain, 20(1). https://doi.org/10.1186/s10194-019-1008-x

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Question

Create a neuro-related CC. Create an ID, CC, HPI, ROS, V/S, physical findings, and assessment with at least 3 differential diagnoses, a final diagnosis, and a treatment plan in a SOAP note format. Use a neuro-related CC that a patient would present within a primary care setting (i.e. no emergency room or ICU type complaints). Examples: regular headaches, migraines, dizziness, dementia or memory loss, weakness, neuropathy, etc..
Include at least two references for your diagnostic and treatment plan. They should be recent (in the last 5-10 years) and peer-reviewed. Use the PA title page, citation, and references. Ensure the treatment plan includes all components (diagnostic plan, therapeutic plan, education plan, and follow-up).

SOAP Note- Evaluation of a Primary Care Patient with Persistent Headaches

The ROS and physical exam in your document should be written up as they would be for a problem-focused visit. The neurological part of the physical exam write-up should be a comprehensive write-up, including everything you assessed in your recording. The neuro portion of the SOAP note is usually a full page or page and a half when done well.

SOAP Note- Evaluation of a Primary Care Patient with Persistent Headaches