Persistent Headache: Episodic SOAP Note. HPI: The patient reports a persistent headache last week but has worsened over the previous two da…
Episodic SOAP Note: Persistent Headache
Initials: TZ Age: 25 Sex: Male Race: African American.
CC: “Persistent headache.”
HPI: The patient reports a persistent headache last week but has worsened over the previous two days. The patient describes the pain as excruciating and pounding, radiating from the head to the neck, and ends in the spine. The patient also reports nausea, vomiting, and excessive tiredness. Movement and noise aggravate the pain. He scales the severity of the pain as 8/10 and 3/10 with ibuprofen medication. He also uses Meclofenamate for headache management.
Ibuprofen 200mg orally daily to manage headache.
Meclofenamate 100mg orally daily to manage pain.
PMHx: No significant medical history. Tetanus immunization was done three weeks ago. No record of surgery.
Soc Hx: Full-time employee at a bank. A soccer fan and occasionally drink beer. Denies use of tobacco and other illicit drugs. Does not use phone or text while driving.
Fam Hx: Married. Father of a three-year-old girl. The daughter is alive and well. The wife is alive and well. The father has diabetes managed through medication. The Mather is well and healthy. Grandparents live in long-term care facilities due to old age.
GENERAL: No weight loss, fever, or chills but reports weakness.
HEENT: Normocephalic. Reports headaches. Eyes: No visual loss. Ears, Nose, Throat: No hearing loss. No loss of sense of smell. No nasal congestion or sore throat.
SKIN: Warm and Dry.
CARDIOVASCULAR: Normal heart rate and sounds. Denies chest pain or discomfort.
RESPIRATORY: Normal breath. Mild cough but no phlegm.
GASTROINTESTINAL: Reports nausea and vomiting but no diarrhea. No abdominal pain or blood.
NEUROLOGICAL: Reports headache but denies numbness of any form. Normal bowel and bladder movements.
MUSCULOSKELETAL: Reports neck and back pain but deny stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: Normal nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: No sweating, cold, or heat intolerance.
VS: BP: 121/71, P: 72, R: 18.5, T: 97.2, Wt: 160, Ht: 5’5’’
General: The patient is alert and oriented x3. Well-dressed but appears fatigued.
HEENT: Head: Normocephalic. EENT: Vision intact. No loss of hearing or smell. No sore throat.
Extremities: Strong and regular pulses. Symmetrical and non-tender joints.
Neurological: MSR2+ symmetrical.
Diagnostic tests: Erythrocyte sedimentation rate (ESR), MRI, CT scan, or Spinal tap.
ESR is a blood test used to detect and rule out inflammation of the brain as the cause of persistent headaches (Singh et al., 2018). A spinal tap involves removing spinal fluid to rule out infections as the cause of constant headaches (WebMD.com, n.d.). MRI and CT provide pictures and images of the brain and can be used to determine if the cause of headache is a brain tumor or internal hemorrhage (Holle & Obermann, 2013).
Holle, D., & Obermann, M. (2013). The role of neuroimaging in the diagnosis of headache disorders. Therapeutic advances in neurological disorders, 6(6), 369-374. 10.1177/1756285613489765
WebMD.com. (n.d.). Spinal Taps for Headache and Migraine Diagnosis. Available at: https://www.webmd.com/migraines-headaches/making-diagnosis-spinal-tap [Accessed 27 May 2021]
Singh, R., Sahbudin, I., & Filer, A. (2018). New headaches with normal inflammatory markers: an early atypical presentation of giant cell arteritis. Case Reports, 2018, bcr-2017. 10.1136/bcr-2017-223240