Posted: September 4th, 2023

Focused SOAP Note

Focused SOAP Note
Patient Information:
D, 72-years old female.
S.
Chief Complaint (CC):
Debilitating headache and neck pain
HPI:
Dickson is a 72-year old female who comes to the clinic with a debilitating headache and neck pain. The patient complains that the problem is not new, but has worsened in the last week and currently it is affecting her vision. She denies of any visual or auditory hallucinations. The patient complains of dry eyes and vision problems. Typically takes 1 to 2 tabs of OTC Naproxen with ‘some help’. “Sleeping it off in a darkened room’ helps alleviate the headache. Rating the pain as 5/10.
Current Medications:
The current medication include Synthroid 100 mcg daily, HCTZ 12.5mg daily, Multivitamin daily, Aspirin 81 mg PO daily, and simvastatin 40mg.
Allergies:
NKDA
PMHx:
Hypertension, Hyperlipidemia, Osteoporosis
PSHx:
No information is available
Soc Hx:
No information is available.
Fam Hx:
No information is available.
ROS:
GENERAL:
The patient complains that her eyes are dry. Her visual acuity is 20/50 OU, 20/40 OD, 20/50 OS. The eyelids are erythematous and edematous with yellow crusting around the lashes.
HEENT:
Eyes: eyes are dry. Her visual acuity is 20/50 OU, 20/40 OD, 20/50 OS. She denies tearing and an itchy, burning sensation in both eyes. The eyelids are erythematous and edematous with yellow crusting around the lashes
Ears: No information is available.
Nose: No information is available.
Throat: No information is available.
SKIN:
No skin condition reported in the past.
CARDIOVASCULAR:
No chest pain, edema, or uncontrolled heart conditions. Diagnosed with hypertension and Hyperlipidemia but they are well-controlled using drugs.
RESPIRATORY:
No respiratory condition like nasal congestion is noted.
GASTROINTESTINAL:
No complaints of abnormal bowel movement, no nausea, vomiting or blood in the stool. GENITOURINARY:
The patient does not complain of dysuria or polyuria or pain while passing urine.
NEUROLOGICAL:
No abnormal bowel and bladder control is noted. Debilitating headache. No dizziness or seizures.
MUSCULOSKELETAL:
No abnormalities noted or back pain.
HEMATOLOGIC:
The patient has no blood disorder or excessive bleeding.
LYMPHATICS:
No history of swollen lymph nodes.
PSYCHIATRIC:
No history of depression or stress. Patient denies suicidal thoughts or ideations.
ENDOCRINOLOGIC:
No abnormal sweating, excessive thirst or fever at night.
ALLERGIES:
NKDA
O.
V.S:
98.1 120/64 HR-72 20
Physical exam:
A physical examination shows that the eyelids are erythematous and edematous with yellow crusting around the lashes. Her visual acuity is 20/50 OU, 20/40 OD, 20/50 OS.
HEENT, CV, Respiratory, Musculoskeletal, Lymphatic, Allergies, and Diagnostic results:
The information from subjective and objective data shows the patient is unwell due to the debilitating headache.
Head: Normal head and neck movement. No bruises or swelling.
Ears: No erythema.
Eyes: Vision problems due to headache.
Nose: No nasal congestion or rhinorrhea.
Throat: No erythema or swelling and clear speech.
Neck: No swelling or palpable lymph.
Cardiovascular: Hypertensive.
Respiratory: Clear lungs and no adventitious sound.
Neurological: She is alert and oriented to person, partially oriented to place but is disoriented to time and place.
Diagnostic Results:
CXR—no cardiopulmonary findings. WNL 2.
CT head—diffuse Cerebral Atrophy
A.
Differential Diagnoses:
a) Cervicogenic:
Cervicogenic is a headache that develops in the neck, although a person feels pain in the neck. It is one of the secondary headaches caused by underlying conditions. Some of the underlying conditions include severe high blood pressure, neck injuries, and infections (Reiley et al., 2017). Others have damaged disc or movement that compresses the nerves around the neck. Some of the conditions’ treatments include active lifestyle, medication, possible surgery, and lowering the blood pressure (Reiley et al., 2017). The condition symptoms include pain around the eyes, a stiff neck, pain on one side of the neck, and headache with specific neck postures. The condition is chronic and may continue for months or years (Barmherzig & Kingston, 2019). Diagnosis of the condition involves manual examination techniques, diagnostic nerve blocks, and medical history evaluation.
Cervicogenic is the possible condition the patient is suffering from due to the similarities in the symptoms.
b) Tension Headache:
Tension headache triggers diffuse, mild to moderate pain. The condition feels like a tight band around the head. The causes of the disease are not well-understood. It occurs at any age, and it is one of the most common types of headache (Eidlitz-Markus et al., 2017). Some of the causes include poor posture, inadequate sleep, and stress. It causes pain on both sides of the head. Some available treatments include pain relievers, stress reduction, and sleeping on good posture (Eidlitz-Markus et al., 2017). It causes dull itching head pain, a sensation of tightness on the forehead, tenderness on the scalp, or shoulder muscles. s
Migraine headache
Migraine headache causes severe throbbing pain, usually on the side of the head. It is accompanied by vomiting, nausea, and extreme sensitivity to light (Mayans & Walling, 2018). The migraine attacks can last for hours or days. The pain can be so severe that it interferes with daily activities. The causes include emotional triggers such as stress, depression, anxiety, and excitement (Mayans & Walling, 2018). Hormonal changes can also trigger the condition, especially during menstruation. Dietary factors include eating certain types of food, alcohol, and caffeine. Menstrual changes are common among women, especially during pregnancy and menopause (Mayans & Walling, 2018). Taking contraceptives can worsen the condition. Patients take pain relievers, triptans, anti-nausea drugs, and opioid medication.
Treatment Plan
Treatment for Cervicogenic involves targeting the cause of the pain in the neck. It varies depending on what works best for individual patients. Some of the best treatments include physical therapy and exercise, medication, and nerve blocks (Jafari et al., 2017). Evidence-based practice shows that a continuous exercise regimen will generate quality results. Manual therapy of the condition involves massage, manipulation, and physical therapy. Treatment focuses on relieving pain or pressure on the joints (Jafari et al., 2017). The patient should also take medication such as tricyclic antidepressants and anti-epileptic drugs.
The patient should exercise daily while going for therapy three times a week. She should take medication daily to relieve the pain. It is essential to sleep in a good posture, avoid stress or high blood pressure (Jafari et al., 2017). The patient should take the medication for high blood pressure consistently to prevent complications. She should eat a balanced diet. It is crucial to avoid stressing activities such as lifting heavy objects.
Patient education involves avoiding activities that can trigger pain or stress on the neck or head. The patient should consult with a physician to assess if the blood pressure is stabilizing or worsening. She should continue taking medication for all the health conditions.
The treatment plan should involve referral to a psychiatrist or counselor to further evaluate the patient’s mental condition. Evidence-based practice shows that depression and stress can spike blood pressure, triggering headaches (Reiley et al., 2017). If the patient had a mental condition such as stress, they should see the counselor for several sessions until their mental health improves drastically.
Reflection
The assessment of the patient’s health condition shows that further information is required for a better evaluation. A medical history should be detailed to establish if some conditions could be causing pain. The patient should continue taking the medication and come back for an assessment to determine if the situation is improving, stabilizing, or worsening.
I learned various lessons during the assessment. One of the lessons is that underlying conditions can trigger pain in the head. For instance, severe blood pressure can cause a headache. The physicians’ responsibility is to ensure they evaluate the underlying conditions to determine the real causes of pain. I also learned that headaches could occur due to different reasons. Thus, the patient needs to come for therapy frequently after the first assessment to evaluate the progress. Some headaches can signal a severe condition that can lead to death or rapture of the blood vessels.
Patient education is essential for the treatment of conditions such as headaches. It is one of the approaches that change the lifestyle that can trigger a headache. For instance, poor sleeping postures, avoiding stress, and eating healthy can transform a patient’s health. I also learned that it is the responsibility of patients to provide adequate information about their health condition. The information is crucial in analyzing the condition a patient may be suffering from.

References
Barmherzig, R., & Kingston, W. (2019). Occipital neuralgia and cervicogenic headache: diagnosis and management. Current Neurology and Neuroscience Reports, 19(5), 20.
Eidlitz-Markus, T., Zolden, S., Haimi-Cohen, Y., & Zeharia, A. (2017). Comparison of comorbidities of migraine and tension headache in a pediatric headache clinic. Cephalalgia, 37(12), 1135-1144.
Jafari, M., Bahrpeyma, F., & Togha, M. (2017). Effect of ischemic compression for cervicogenic headache and elastic behavior of active trigger point in the sternocleidomastoid muscle using ultrasound imaging. Journal of Bodywork and Movement Therapies, 21(4), 933-939.
Mayans, L., & Walling, A. (2018). Acute migraine headache: treatment strategies. American Family Physician, 97(4), 243-251.
Reiley, A. S., Vickory, F. M., Funderburg, S. E., Cesario, R. A., & Clendaniel, R. A. (2017). How to diagnose cervicogenic dizziness. Archives of Physiotherapy, 7(1), 12.

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