SOAP NOTE - MIGRAINE | Free Essay Example

SOAP NOTE – MIGRAINE

ID:

Subjective:

CC: “I have been experiencing a strong headache that does not resolve even when I take Tylenol.”

HPI: P.B. is a 44-year-old female presenting with complaints of headache pain. The headaches began five years ago and have been on and off. The headaches are mostly unilateral, localized on the right side of the head. They often appear once or twice a month and may last a few minutes or hours. The headaches are throbbing. The pain is aggravated by activity, especially physical and rigorous activities, and relieved by rest or medication. She usually takes Tylenol to offset her headaches. The headaches are intermittent and are sometimes preceded by a sensation of extreme fatigue, dizziness, and sweats. Whenever the headaches occur, the headaches are often severe and debilitating and prevent her from going to work or performing her activities of daily living. The pain intensity score of the headache is 8/10/ The patient also reported that she experienced blind spots, stars, and blurry zigzag lines just before the headaches.

Past Medical History:

Medical problem list

The patient is a known hypertensive and is currently on anti-hypertensive medications.

Surgical:

The patient had a cesarian section during the birth of her lastborn.
Tooth extraction in January.
Preventive Care:
The patient had a dental examination in January that resulted in one of her teeth being removed.
A breast examination in December last year was negative for any breast anomalies.

Allergies:

No known drug or food allergies

Medications:

Tylenol 1g, taken every 8 hours
Depo-provera injection, administered two weeks ago
Enalapril 5mg, taken every 24 hours

Immunizations:

She is up to date with all her childhood vaccines.
She took her annual influenza virus vaccine in April.
She has completed her COVID-19 vaccines, which included two booster shots.

Social History:

Chemical history: The patient is a social smoker. She smokes up to two cigarettes at social events. She also drinks socially and has a preference for red wine. She, however, denies using any illicit substances.

Sexual history and contraception/protection: The patient is sexually active. She engages in sexual intercourse regularly with her husband. She denies having had sexual encounters with other partners. She also denies having had STIs or other reproductive tract infections before. Her healthcare-seeking behavior and reproductive health are also excellent, as she regularly participates in STI, UTI, and reproductive health screening exercises. She was started on an injectable contraceptive two weeks ago.

Other:

A.D. works as a receptionist in a local organization. She lives with her husband and two children, aged 10 and 7, in a rented apartment. She is considerably keen on her diet. She notes that she takes a balanced diet but has a liking for meat. She also takes two cups of coffee every day. She exercises mildly every day after work. A.D. is a staunch Christian with firm beliefs in Christian values and faith.

Safety:

The patient is a gun owner. She, however, notes that she keeps her gun in a closed cabinet away from her children. She feels safe in her residence. She also practices safety behaviors such as wearing a helmet and safety belts when performing outdoor activities.

Family History:

Both of her parents are still alive. She has a history of on-and-off migraine headaches and has been on preventive medications for the migraine. Her father is allergic to pollen and has a history of recurrent allergic dermatitis and allergic rhinitis.

Review of Systems

Constitutional: The patient denies any recent weight loss. She also denies experiencing fever or chills.

Eyes: The patient reports occasional abrupt vision loss and scintillation, occurring before the episodic headaches. She, however, denies experiencing any vision changes during off-episodes of headache. She also denies double vision, eye discharge, or a recent eye infection.

Ears/Nose/Mouth/Throat: Denies hearing loss, ear discharge, or ringing in the ears. The patient also denies nasal discharge, sore throat, mouth ulcerations, or pain during swallowing. The patient denies experiencing any unusual gum bleeding or epistaxis in the recent past.

Cardiovascular: The patient denies chest pain or palpitation. She also denies having any swelling in her extremities.

Pulmonary: The patient denies experiencing any wheezing, shortness of breath, or labored breathing. She also denies any excessive coughs.

Gastrointestinal: Denies abdominal pain, bowel distension, bowel movement inconsistencies, or abdominal tenderness.

Genitourinary: Denies dysuria, urinary urgency, and frequency, or pain during coitus.

Musculoskeletal: The patient denies muscle pain, joint stiffness, or restrictions in her mobility and joint range of motion. She also denies muscular stiffness.

Integumentary & breast: The patient denies having any skin lesions, scars, nodules, hyperpigmentation, or any other color changes in her skin, except for a surgical scar in her lower abdomen. She also denies having any breast tenderness or pain.

Neurological: The patient denies dizziness or syncope. She, however, reports sporadic headaches over the past week.

Psychiatric: The patient denies any anxiety or depression.

Endocrine: Denies any recent weight gain or weight loss. She also denies having heat or cold intolerance.

Hematologic/Lymphatic: The patient denies having any lymphatic swelling, lymph node enlargement, or splenomegaly. She also denies ease of bruising or excessive bleeding.

Allergic/Immunologic: The patient has no known drug or food allergies.

Objective

Height 5’11 | Weight 180 lbs. | BMI 25.1

Labs, radiology, or other pertinent studies:

Complete Blood Count for P.B.: This test was necessitated to measure the levels of RBC and WBC, as well as to give insight into the presence of anemia and a likely inflammatory process.

Hematology	Result	Normal range
Red cell count	4.5 x 10¹²/L	4.5–5.7
White cell count	11 x 10⁹/L	4.0–10.0
Hemoglobin	150 g/L	133–167
Hematocrit	0.50	0.35–0.53
MCV	80 fL	77–98
MCH	27 pg	26–33
MCHC	332 g/L	330–370
RDW	10.5%	10.3–15.3

Physical Exam

General Survey: No signs of significant weight loss or fatigue.

HEENT: The head is well-rounded and normocephalic. The hair is evenly distributed on the scalp. There are no signs of alopecia or abnormal hair thickening. There are no signs of depression, swelling, or scars. The eyes are symmetrical. The vision is intact. There are no signs of eye discharge, corneal dystrophy, cataracts, or astigmatism. The ears are also symmetrical and consistent in coloration. No signs of ear discharge. The nose is midline and symmetrical. No signs of nasal discharge, tenderness, or scars. No signs of buccal ulcerations, color inconsistencies, or uvula deviation.

CVS: The heart rate is rhythmic. No sign of jugular venous distension or swelling in the extremities. Also, no pericardial friction rub or gallop sounds were heard on auscultation.

Chest/Thorax: The chest wall is symmetrical. The respiratory rate was rhythmic, with no signs of labored breathing or use of accessory muscles of inspiration. The chest wall was also normative in curvature, with no signs of kyphosis or scoliosis on inspecting the chest wall.

Abdominal: The abdomen is symmetrical and well-rounded. There is a notable surgical scar on her lower abdomen. There is no sign of guarding, skin color inconsistencies, striae, or vein engorgement. There are also no signs of abdominal masses or distension. There are no signs of abdominal distension, tenderness, or pain.

Musculoskeletal: No signs of muscle stiffness, muscle pain, or limitation in the range of motion on both passive and active movements. There are also no signs of joint swelling.

Integumentary: The skin was consistent in coloration. There was no sign of cyanosis or finger clubbing on the extremities. The capillary refill time on the upper and lower limbs was 2 seconds.

Neurological Examination: The patient is alert and responsive. She answers the interview questions appropriately and can follow a three-stepped contralateral localization command. She is also aware of her surroundings, oriented to the event and place, and dressed appropriately for the occasion. Her speech is intact, goal-directed, clear, and logical. Her tone is normative, with no signs of slurred speech. Her memory and thought process are intact, and her reasoning is logical.

Assessment

Differential Diagnoses

Migraine with Aura ICD 10 Code G43.1: Migraine is a disorder characterized by a moderate to severe headache. The headache usually manifests as a unilateral headache and is of pulsating or throbbing character. A distinguishing feature of migraine with aura is the presence of a constellation of symptoms such as visual, sensory, language, and speech disturbances that preceded the headaches. Migraine with aura are recurrent headache attacks that last minutes and are unilaterally localized. Patients with this condition will often present with complaints of episodic unilateral headaches that last minutes and are preceded by light or sound sensitivity (Eigenbrodt et al., 2021). The patient in the case presented had unilateral headaches of pulsating character. Likewise, the headache was preceded by light sensitivity and sometimes nausea. These manifestations are consistent with those of migraine with aura, warranting the inclusion of this differential.
Migraine without aura ICD-10 Code G43.009: Migraine without aura is the most common form of migraine headaches, accounting for over 75% of all cases. Migraine without aura usually manifests as recurrent headaches that often last between 4 and 72 hours, are unilaterally localized, are moderate to severe in intensity, aggravated by activity and relieved by rest, and are accompanied by photophobia or phonophobia (Aguilar-Shea et al., 2022). The patient in the case presented had unilateral headaches of pulsating quality. The headaches were also episodic and were sometimes accompanied by visual changes. This warranted the inclusion of this differential in the list. This diagnosis is, however, ruled out due to the presence of aura in the case presented.
Cluster Headache ICD-10 Code G44.009: Cluster headaches are short-term, severe, unilateral headaches. They are usually accompanied by at least one autonomic symptom. The most common autonomic manifestation that accompanies these headaches include lacrimation, conjunctival injection, and aural fullness, among others. Cluster headaches are the most common form of trigeminal autonomic cephalgias, affecting about 0.1% of the population (Ray et al., 2022). Alcohol consumption, family history, and age above 30 are known risk factors for the condition. Patients with cluster headaches will commonly present with unilateral headaches similar to those seen in migraine headaches. Unlike migraines, the photophobia and phonophobia seen in cluster headaches are usually ipsilateral, while in migraine attacks, the phonophobia and photophobia are experienced bilaterally (Al-Karagholi et al., 2022). The patient in the case presented had a unilateral headache, warranting the inclusion of this differential. The absence of autonomic symptoms in the patient’s case ruled out this diagnosis.

Diagnosis: The presumptive diagnosis in the case presented is migraine with aura. According to the International Classification of Headache Disorders (ICHD-3) criteria for migraine with aura, the presence of any of the defining symptoms of aura is warranted to make the diagnosis. These include retinal, visual, sensory, motor, and brainstem manifestation (Eigenbrodt et al., 2021). The patient manifested symptoms consistent with those of migraine headaches. The presence of aura in the patient’s case, demonstrated by scintillation and scotoma, presented rules out migraine without aura. Likewise, the absence of autonomic symptoms, such as lacrimation, ipsilateral phonophonia, and photophobia, ruled out cluster headaches.

Plan

Migraine with Aura ICD 10 Code G43.1:

Diagnostics:

Neuroimaging to rule out a possible brain pathology. Some brain pathologies can manifest with moderate to severe headaches (Eigenbrodt et al., 2021).
Cerebrospinal fluid analysis to rule out a possible meningococcal infection. Meningococcal infections commonly present with severe headaches (Eigenbrodt et al., 2021).

Treatment

The patient will be started on Naproxen 275 mg every 12 hours and sumatriptan 50m OD dose. NSAIDs such as naproxen and triptans such as sumatriptan are approved medications for abortive management of migraine headaches (Eigenbrodt et al., 2021).
NSAIDs maintain effectiveness in managing headaches. Triptans are also equally effective in managing migraine headaches (Eigenbrodt et al., 2021).
Using NSAIDs along with triptans is recommended for moderate to severe diseases. When used together, their effects in pain relief are superior to either agent used alone (Eigenbrodt et al., 2021).
The patient in the case presented will thus be started on both agents for maximal therapeutic effects. The dosing duration should be kept at not more than ten days a month to prevent medication overuse (Eigenbrodt et al., 2021).

Education:

The patient will be educated on the disease process and the available therapeutic options. In this respect, she will be told that migraines are a complex disorder and if left unmanaged, may cause significant debilitation and deterioration in the quality of life of an individual (Aguilar-Shea et al., 2022) .
Disease complications such as migrainous infarction and status migrainous are also likely if the disease is under-addressed (Aguilar-Shea et al., 2022).
The patient will also be educated on the preventive approaches against migraine headaches. These include the likely triggers of migraine attacks and the therapeutic options available for preventive care against migraines. The preventive medications against migraine attacks include beta-blockers such as propranolol, antidepressants such as amitriptyline, and anticonvulsants such as valproate. These medications are effective in reducing the frequency of attacks. They also improve the responsiveness of acute migraine attacks to medications (Numthavaj et al., 2024).
The patients should be advised to consider this approach to prevent more severe and frequent attacks. Likewise, the patient should be advised to avoid known triggers for migraine attacks. Red wine, stress, and alcohol ingestion can trigger migraine attacks (Numthavaj et al., 2024).
The patient, being a red wine lover, should be advised to minimize her consumption of red wine as a measure for preventing frequent migraine attacks (Numthavaj et al., 2024).
The patient will also be advised to take their medications as prescribed for adequate management of the headache. She should, however, be educated on the potential side effects of the prescribed medications and administration considerations (Numthavaj et al., 2024).
Naproxen, like other NSAIDs, has the potential to cause GI irritation and should not be taken on an empty stomach. This may increase the likelihood of developing stomach ulcers. They can also cause headaches and dizziness (Sohail et al., 2023).
Likewise, sumatriptan can cause GI disturbances, headaches, and muscle stiffness. The patient should be advised to contact the clinic whenever they experience severe side effects, as they may warrant dosing adjustments (Gendolla et al., 2021).

Follow-Up:

The patient is expected to return for follow-up after the completion of the 10-day therapy. She can, however, return whenever she experiences unexplained side effects of the medication or when the headaches worsen.

Hypertension ICD 10 Code 110:

Diagnostics

A CBC with differential will be ordered to rule out other factors that may have been causing the elevation of blood pressure. Savedchuk et al. (2022) note that infections and inflammatory processes can considerably increase BP readings in patients with known hypertension.
A thyroid profile will also be considered to eliminate hyperthyroidism as the likely cause of elevated blood pressure (Harrison et al., 2021).
12-lead ECG to document cardiac rhythm and identify left ventricular hypertrophy (Harrison et al., 2021)
Fundoscopy to check for retinopathy may also be important. Retinopathy and subsequent visual changes suggestive of end-organ damage are usually observed in poorly controlled hypertension (Harrison et al., 2021).

Treatment

The patient will be continued on anti-hypertensive medications. Before revising the dose, it is important to determine whether the patient has been taking her medications as prescribed. Poor compliance with anti-hypertensive medications is a leading cause of treatment failures in the comprehensive management of hypertension (Harrison et al., 2021).
The patient, in the case presented, may not have been taking her medications as prescribed. If it is determined that poor medication adherence is the problem, the patient will be advised to continue taking the medication as previously prescribed (Edwards et al., 2022).
Dose revision and therapeutic adjustments may be preferred when BP control is not attained in the current dose. According to the American Heart Association, upward dose adjustments are favored when BP control is not optimal at lower doses of an angiotensin-converting enzyme Inhibitor (Harrison et al., 2021). For this reason, increasing the dose of Enalapril to 7.5mg may be recommended.

Education:

The patient will be educated on the disease process. She will be told that hypertension is a chronic disorder that requires lifelong management with anti-hypertensive medications to prevent hypertensive complications and subsequent suffering. If poorly controlled, the chances of developing hypertensive complications, such as retinopathy, chronic kidney disease, and stroke, increase (Harrison et al., 2021).
The patient will also be educated on the significance of medication adherence in ensuring optimal BP control. She will also be told of the non-pharmacological measures that could help her attain optimal BP control (Harrison et al., 2021).
Non-pharmacological interventions such as salt restrictions, exercise, reduction in alcohol intake, and smoking cessation can help optimize BP control. The patients can thus apply these measures to improve the prognosis of their disease (Harrison et al., 2021).
The patients should also be equipped with self-care techniques, such as BP measurements, to improve accountability for their disease management (Harrison et al., 2021).

Follow-up:

The patient should return for follow-up after one month. It is expected that the BP control will be optimal by then. A referral to a cardiologist may be necessary when the BP control is not optimized by the time she returns to the clinic (Harrison et al., 2021).

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

Al-Karagholi, M. A.-M., Peng, K.-P., Petersen, A. S., De Boer, I., Terwindt, G. M., & Ashina, M. (2022). Debate: Are cluster headache and migraine distinct headache disorders? The Journal of Headache and Pain, 23(1). https://doi.org/10.1186/s10194-022-01504-x

Edwards, E. W., Saari, H. D., & DiPette, D. J. (2022). Inadequate hypertension control rates: A global concern for countries of all income levels. The Journal of Clinical Hypertension, 24(3), 362–364. https://doi.org/10.1111/jch.14444

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., … Ashina, M. (2021). Diagnosis and management of migraine in ten steps. Nature Reviews Neurology, 17(8), 501–514. https://doi.org/10.1038/s41582-021-00509-5

Gendolla, A., Rauer, N., Kraemer, S., Schwerdtner, I., & Straube, A. (2021). Epidemiology, demographics, Triptan contraindications, and prescription patterns of patients with migraine: A German claims database study. Neurology and Therapy, 11(1), 167–183. https://doi.org/10.1007/s40120-021-00304-w

Harrison, D. G., Coffman, T. M., & Wilcox, C. S. (2021). Pathophysiology of hypertension. Circulation Research, 128(7), 847–863. https://doi.org/10.1161/circresaha.121.318082

Mohammadi, M., Ayoobi, F., Khalili, P., Soltani, N., La Vecchia, C., & Vakilian, A. (2021). Relation of hypertension with episodic primary headaches and chronic primary headaches in the population of Rafsanjan Cohort Study. Scientific Reports, 11(1). https://doi.org/10.1038/s41598-021-03377-7

Numthavaj, P., Anothaisintawee, T., Attia, J., McKay, G., & Thakkinstian, A. (2024). Efficacy of migraine prophylaxis treatments for treatment-naïve patients and those with prior treatment failure: A protocol for systematic review and network meta-analysis of Randomised Controlled Trials. BMJ Open, 14(3). https://doi.org/10.1136/bmjopen-2023-077916

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

Savedchuk, S., Raslan, R., Nystrom, S., & Sparks, M. A. (2022). Emerging viral infections and the potential impact on hypertension, cardiovascular disease, and kidney disease. Circulation Research, 130(10), 1618–1641. https://doi.org/10.1161/circresaha.122.320873

Sohail, R., Mathew, M., Patel, K. K., Reddy, S. A., Haider, Z., Naria, M., Habib, A., Abdin, Z. U., Razzaq Chaudhry, W., & Akbar, A. (2023). Effects of non-steroidal anti-inflammatory drugs (NSAIDs) and gastroprotective NSAIDs on the gastrointestinal tract: A narrative review. Cureus. https://doi.org/10.7759/cureus.37080

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SOAP NOTE – MIGRAINE

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SOAP NOTE – MIGRAINE