Episodic/Focused Note About The Patient Complaining Of Headache

Episodic/Focused Note About The Patient Complaining Of Headache

Case Study 1: Headaches

A 40 year old female presents with 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 Episodic/Focused Note About The Patient Complaining Of Headache.

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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.

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 Episodic/Focused Note About The Patient Complaining Of Headache

Patient Information:

Initials: C. H Age: 40yo Sex: Female Race: Not stated

CC (chief complaint): “Headache.”

HPI: The client is a 40yo female who presents to the clinic complaint of a headache that started a week ago. The client further reports “head cold” that started 3 weeks ago. She reports increase in severity of sinus symptoms. The client experienced pain across her forehead, which she described as pressure behind her eyes. She further reported inability to breathe through her nose. The client further feels some mucus running down at the back of her throat. She further reported nonproductive cough that occurs occasionally, fever, frequent sneezing, and reduced appetite. The headache worsen when bending over and improves after taking acetaminophen improves my headache. However, the drug does not take the headache away. She also takes Sudafed HCL 120 mg every 12 hours to relief the pain. The severity of the symptoms increases in the morning. The client reports difficulty concentration at job and feeling fatigued.

Location: Head

Onset: Head cold” 3 weeks ago and headache a week ago

Character: Pressure behind the eyes

Associated signs and symptoms: Nonproductive cough that occurs occasionally, fever, frequent sneezing, and reduced appetite.

Timing: The severity of the symptoms increases in the morning

Relieving factor and accelerating factor: The headache worsen when bending over and improves after taking acetaminophen Episodic/Focused Note About The Patient Complaining Of Headache.

Severity: 8/10.

Current Medications: Acetaminophen and Sudafed HCL 120 mg every 12 hours taken to relief the pain.

Allergies: Denies food or drug allergies.

PMHx: The client’s childhood immunization is up to date.

Soc Hx: The client is married with two kids. She lives within the city with her husband and their children. She denies smoking or use of other illegal substances. The client enjoys going to the gym during her free time. She takes a glass of coffee daily before retiring to bed.

Fam Hx: Her parents are alive. Her father is 85yo with diabetes type 2 and hypertension. Her mother is 79 with asthma. She has two siblings who are healthy with no known health issues. Her children two are healthy. Episodic/Focused Note About The Patient Complaining Of Headache

ROS:

GENERAL: The client reports fatigue and fever.

HEENT: Reports headache. Denies blurred vision. Reports pain behind the eyes. Denies hearing loss. Reports frequent sneezing and inability to breathe through her nose. Reports feeling some mucus running down at the back of her throat.

SKIN: Denies rashes

CARDIOVASCULAR: Denies chest discomfort

RESPIRATORY: Reports nonproductive cough. Denies shortness of breath.

GASTROINTESTINAL: Denies abdominal pain or anorexia

GENITOURINARY: Denies frequent or painful urination.

NEUROLOGICAL: Reports headache. Denies paralysis, numbness, dizziness, or tingling in the extremities.

MUSCULOSKELETAL: Denies back pain or muscle stiffness.

HEMATOLOGIC: Denies excessive bleeding.

LYMPHATICS: Denies enlarged lymph nodes.

PSYCHIATRIC: Denies anxiety.

ENDOCRINOLOGIC: Denies excessive sweating.

ALLERGIES: Denies eczema or hives.

Physical exam:

Vitals: Bp 135/87; RR 18; Os 97%; Weight 72kgs; and height 5 “3”

HEENT: No scars seen on the head. No tears from the eyes. No discharge from the years. No evidence of nasal congestion or runny nose. No swollen sore throats.

General: The client is a 40 yo female presented to the clinic with headache. She is well-developed and well-nourished. The client is appropriately dressed based on today’s weather and time of the year. She is attentive and maintains eye-contact throughout the clinical interview. She seems to be in mild distress. She speaks in normal tone and volume. She is future-oriented and goal-directed. She is alert and oriented to places, persons, time, and event Episodic/Focused Note About The Patient Complaining Of Headache

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Diagnostic results:

Differential Diagnoses

Sinus headache,
Migraines,
Cluster headaches,
Occipital neuralgia, and
Angle-closure glaucoma.

Sinus headache: This condition qualifies as the primary diagnosis for this client. Sinus headache is characterized by pain, pressure on the forehead, cheeks, or brows, pain worsen while bending, stuffy nose, fatigue, loss of sense of smell, mucus dripping from the nose down the throat, sore throat, fever, tiredness, cough, and bad breath (Lipton et al., 2018)Episodic/Focused Note About The Patient Complaining Of Headache. The client reported headache that feels like pressure behind the eyes, fever, frequent sneezing and inability to breathe through her nose, tiredness, and nonproductive cough, qualifying for this diagnosis.

Migraines: Migraines is characterized by headaches accompanied by pain around the eyes (Buse et al., 2020). The client reports headache that feels like pressure behind the eyes, qualifying for this diagnosis. However, migraines was ruled out since other pertinent symptoms, including nausea, weakness, and mood changes were absent.

Cluster headaches: This type of headache occurs for several days or weeks before it disappears for months. It is associated with severe one-sided headaches accompanied with extreme pain around or behind one eye (May et al., 2018). The client reported headache that feels like pressure behind the eyes, qualifying for this diagnosis. However, cluster headaches is ruled out since other pertinent symptoms, including a droopy eyelid, stuffy runny nose, and red watery eye on the affected side were absent.

Occipital neuralgia: This type of headache starts in the upper back of the head and across the scalp and to the eyes with bursts of pain (Janjua et al., 2020). The client qualifies for this diagnosis since she reported headache that feels like pressure behind the eyes. However, occipital neuralgia is ruled out since the client’s headache is not accompanied with outbursts pain.

Angle-closure glaucoma: This condition is mainly characterized by severe headache that occurs behind the eyes and nauseas (Zhu et al., 2019). Glaucoma affects optic nerves resulting in loss in peripheral vision, halos around lights and challenges in adapting to darkness, and blurred vision (Zhu et al., 2019)Episodic/Focused Note About The Patient Complaining Of Headache. The client qualifies for this diagnosis since she reported headache accompanied with pressure behind the eyes. Nonetheless, this condition is ruled out since blurred vision or challenges in adapting to darkness were not reported.

References

Buse, D. C., Reed, M. L., Fanning, K. M., Bostic, R., Dodick, D. W., Schwedt, T. J., … & Lipton, R. B. (2020). Comorbid and co-occurring conditions in migraine and associated risk of increasing headache pain intensity and headache frequency: results of the migraine in America symptoms and treatment (MAST) study. The journal of headache and pain, 21(1), 1-16.

Janjua, M. B., Reddy, S., El Ahmadieh, T. Y., Ban, V. S., Ozturk, A. K., Hwang, S. W., … & Arlet, V. (2020). Occipital neuralgia: A neurosurgical perspective. Journal of Clinical Neuroscience, 71, 263-270.

Lipton, R. B., Munjal, S., Alam, A., Buse, D. C., Fanning, K. M., Reed, M. L., … & Dodick, D. W. (2018). Migraine in America Symptoms and Treatment (MAST) study: baseline study methods, treatment patterns, and gender differences. Headache: The Journal of Head and Face Pain, 58(9), 1408-1426.

May, A., Schwedt, T. J., Magis, D., Pozo-Rosich, P., Evers, S., & Wang, S. J. (2018). Cluster headache. Nature reviews Disease primers, 4(1), 1-17.

Zhu, X., Zeng, W., Wu, S., Chen, X., Zheng, T., & Ke, M. (2019). Measurement of retinal changes in primary acute angle closure glaucoma under different durations of symptoms. Journal of Ophthalmology; 2 (3): 1-7 Episodic/Focused Note About The Patient Complaining Of Headache.

Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example: Episodic/Focused Note About The Patient Complaining Of Headache

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use)Episodic/Focused Note About The Patient Complaining Of Headache, any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: Denies weight loss, fever, chills, weakness or fatigue.

HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN: Denies rash or itching.

CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: Denies shortness of breath, cough or sputum.

GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY. Episodic/Focused Note About The Patient Complaining Of Headache

NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC: Denies anemia, bleeding or bruising.

LYMPHATICS: Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC: Denies history of depression or anxiety.

ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

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Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7^th edition formatting Episodic/Focused Note About The Patient Complaining Of Headache