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Headache soap note

31/12/2020 Client: saad24vbs Deadline: 24 Hours

Pediatric SOAP Note


Name: P. L


Date: 03/09/2018


Sex: Male


Age/DOB/Place of Birth: 16 y.o/03/01/2001/Cuba


SUBJECTIVE


Historian: Mother and patient


Present Concerns/CC: “I’ve been having horrible headaches on and off for the last 2 weeks”


Child Profile:


Patient is a high school student with no significant past medical history. He is enrolled in a dual program where he is taking college classes in advance. Described by his mother as an A+ student. He does participate in sports at school being part of the baseball league. Patient goes to school during the day and spends most of his free time studying. He eats a balanced diet including meat, vegetables, and salads. Patient drinks water throughout the day and does not like soda beverages. Denies drinking energetic drinks. He uses seatbelt at all times while in a car.


HPI:


Otherwise healthy 16 y/o male seen in the office for complaints of daily headache for 2 weeks. Pain is described as dull and pounding and intermittent. Pain is mainly located in the back of the head but at times radiates to the top and to the sides. Patient can’t say if there are specific triggers for the pain because he experiences it at any time. Pain is alleviated by rest and in other instances he has taken Excedrin Extra Strength with little relief. Denies photophobia, blurred vision, or diplopia. Patient admits to some pressure with the studies as he is trying to get a full scholarship for university.


Med


Medications:


 He is not currently taking any medications. Has taken Excedrin Extra Strength 1 tab orally by mouth as needed for headache in the past.


PMHX:


Allergies: NKA


Medication Intolerances: None


Chronic Illnesses/Major traumas: None


Hospitalizations/Surgeries: None


Immunizations: Up to date


Family History


Mother and father alive. Mother has history of GERD and father suffers from HTN. Paternal grandparents are deceased. Both of old age. Maternal grandfather and maternal grandmother are alive, and they only suffer from GERD and OA.


Social History


Patient is only child and lives with his parents. He is currently on high school. He is enrolled in a dual program where he is taking college classes in advance. He spends most of his time studying. He has applied to various universities and expects to obtain full scholarship. Mother denies guns at home or exposure to second hand smoking. Patient does not work because his school requires him to spend a great amount of time to it. Both parents are very supportive of patient. Patient denies being sexually active and denies having a girlfriend. He has a group of close friends.


ROS


General


Denies fever, weight loss or generalized weakness


Cardiovascular


Denies chest discomfort, palpitations, or chest pressure


Skin


Denies open wounds, rash, or hives


Respiratory


Denies for hemoptysis, tachypnea, dyspnea or cough


Eyes


Denies blurred vision, diplopia, and sense of curtain falling or intolerance of light. Positive for reading glasses.


Gastrointestinal


Denies nausea, vomiting, lack of appetite or changes in bowel habits


Ears


Denies ear pain, tinnitus, or discharge


Genitourinary/Gynecological


Denies changes in urine color, dysuria, or hematuria


Nose/Mouth/Throat


Denies mouth sores, epistaxis, nasal congestion, or difficulty swallowing


Musculoskeletal


Denies joint swelling, stiffness, or pain


Breast


Not examined


Neurological


Report headaches x 3 weeks. Negative for paralysis, tremors, seizures, speech difficulty or confusion


Heme/Lymph/Endo


Denies fatigue, anemia, cold/heat intolerance or enlarged lymph nodes


Psychiatric


Denies problems falling asleep or staying asleep, depression or suicidal ideations. Positive for high levels of stress and some anxiety


Weight 164 lbs


Temp 98.7


BP 122/63


Height 5’7”


Pulse 72


Resp: 18


General Appearance and parent‐child interaction:


Cooperative and calm patient accompanied by his mother. Both with clear and appropriate speech and language


Skin


Skin is intact. Good turgor. Capillary refill 2 seconds


HEENT


Head: Normocephalic, atraumatic. Eyes: symmetric. Normal eye lashes and lids, Clear conjunctiva. Visual fields full to confrontation. No ptosis. Pupils PERRLA. Ears: No trauma or drainage. Nontender tragus. Mouth: Intact gag reflex. Nose: Patent nares with midline septum. Neck: supple with no JVD and full ROM.


Cardiovascular


Normal heart rate and sounds. Pedal pulses 2+ bil. No cyanosis, clubbing or edema of the lower extremities


Respiratory


Lung fields clear to auscultation. Respiratory rate within normal parameter. Symmetric chest wall expansion. No use of accessory muscles observed.


Gastrointestinal


Abdomen is flat with normoactive bowel sounds in all quadrants. Exam negative for tenderness or guarding


Breast


Not examined during this visit


Genitourinary


No bladder distention or CVA tenderness


Musculoskeletal


Patient with full ROM. Normal spinal curvature and good head control. No joint deformities or inflammation seen.


Neurological


Extremities movable 5/5 strength. Intact coordination with finger to nose test. Intact sensation to light and deep touch. Reflexes 2 + throughout. Romberg test negative.


Psychiatric


Patient with adequate engagement in conversation, normal mood, no indications of depression at this time


In-house Lab Tests – document tests (results or pending)


MRI of the brain and cervical spine: Exam to be completed in an outpatient imaging


center as soon as possible


Diagnosis




Primary Diagnosis:


· Tension headache (G44.209): This diagnosis was selected based on physical examination and history of recent exposure to higher levels of stress. Pending MRI results to rule out other causes if any.


· Plan including education


· MRI scheduled for next day.


· Start Midrin 325 mg take 1 cap every 4 hours as needed for severe headache. Do not exceed 8 capsules per day.


· Motrin 800 mg 1 tablet every 8 hours as needed for pain


· Follow up in the office for tests results


Education


· Patient and mother educated about tension headaches and that they could be related to high stress levels. However, further testing was ordered to rule out other possible causes. Patient verbalized understanding and agreed to additional test to rule out more serious causes


Educated to keep a log with frequency of headaches


Instructed to take medications as prescribed and do not exceed recommended dosage.


Educated about the importance of a life –school balance, participate in physical activities, getting sufficient sleep and proper nutrition


Use relaxation and deep breathing techniques and take frequent brakes while using computer or other electronic devices (Donaldson, 2016)




Differential diagnosis -


1. Tension headache (G44.209): Tension headaches are


often described as dull pain on the back of the head or in


forehead. They are also called stress headaches and they


are often the result to high level of stress (Donaldson,


2016).


2. Brain tumor (C71.9): While many cases are


asymptomatic, a new onset of headache can warrant


further testing to rule out this diagnosis. According to


Prosad Paul, Perrow & Webster (2014), patients with


brain tumors can have persistent headaches, problems


with coordination, dizziness, fatigue or weakness. This


patient does not present other symptoms; however, this


differential diagnosis is a must no miss and therefore is


included for this patient.


3. Herniated cervical disk (M50.10): Although not very


common, serious cervical pathologies such as herniated


disk can cause headaches (Donaldson, 2016).


References:


Donaldson, S. (2016). Tension Headaches: Psychological Factors. Biofeedback,


44(1), 15-18. doi:10.5298/1081-5937-44.1.06


Prosad Paul, S., Perrow, R., & Webster, M. A. (2014). Brain tumours in children:


reducing time to diagnosis. Emergency Nurse, 22(1), 32-36.

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