NURS 620 migraine soap note.docx | (Already Grade A)

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Running head: MIGRAINE SOAP NOTE Migraine Soap Note Migraine Soap Note Subjective: CC: “I have been experiencing serious incidence ... s of headache for the past three days and in wish to have it evaluated.” HPI: The 35-year-old white female presents to the health facility complaining of severe headache for the past three days and requests for evaluation. In a scale of 1-10, the patient rates the pain at 8. She indicates that the headache has a throbbing sensation with its location being at the temporal region. The pain begun three days ago as the patient prepared breakfast and she has recently notes light sensitivity and nausea. She indicates to have experienced such headaches in the past. The headache, as reported by the patient, lasts for close to one hour after its onset. She indicates that it can occur twice a day or even three times. She denies being aware of any aggravating factors for the headache. Taking Ibuprofen and taking rest in a dark room have been providing relief. She denies incidences of neck pain, loss of hearing and fever. Medical History: The patient was diagnosed with type II diabetes and high cholesterol 6 years ago. The patent has been under medication to control and manage the diseases. She also takes a balanced diet and regular exercises to remain healthy. She denies any other illnesses in her childhood or adulthood. All he immunizations are fully updated with the recent one being a flu vaccine on 11/15. Surgical History: None OBGYN: L-2 T-2 A-0 G-2 P-O Medications: 400 mg Ibuprofen orally after every 6 hours to control the headache. Oral 20mg Lipitor and 2mg Amaryl. Allergies: Denies having any allergies. Social History: The patient is married and living with the husband together with their two girl children aged 9 and 6 years. She is a qualified accountant working 5 kilometers from their houses in a car dealership company. The husband is a civil engineer and works as a contractor. The patient works for three days a week in shifts lasting for 12 hours. They are staunch Christians and attend church regularly. They have a family gym and are all active with a daily commitment of 20 minutes when the wife is free. She also runs for 6 km thrice a week. She denies drinking alcohol, using tobacco or using any illicit drugs. Family History: The mother is 60 years and positive for diabetes diagnosed 15 years ago. The father is alive aged 65 years and suffering from colon cancer. The family does not have a history of anemia, mental illness, kidney disease or epilepsy. Review of Systems: General: The patient is generally healthy with no complications. She denies weigh loss or gain, fever, fatigue, chills and weakness. Skin, hair and nails: Denies any changes in appearance, skin rashes, sores and lumps. Denies mole color and size changes. HEENT: Reports temporal region throbbing headache. Denes dizziness or trauma. Denies daily vision problems. Reports light sensitivity during headache. Denies itching, drainage and redness. Denies diplopia, flashing lights and spots. Denies hearing problems, tinnitus, infections and vertigo. Denies nasal congestion, nasal conditions that are abnormal and rhinorrhea. Denies any problems in the throat, dental carries, gingivitis, canker sores or cold sores. Thorax: Patient denies neck pain, lumps or swollen glands. Denies asthma, any allergies or lung disease. Breast: Denies nipple discharge, discomfort or pain. Respiratory: Denies congestion, shortness of breath, coughing, and wheezing. Cardiovascular: Denies tightness, pressure and chest pain. Does not complain of cyanosis, palpitations and tachycardia. Reports high levels of cholesterol. PVS: Denies ulcers, extremity edema, varicose veins , leg cramps and coldness. Gastrointestinal: Patient is on diabetic diet. Reports nausea after headache onset. Denies abdominal pain, diarrhea and vomiting. Has regular bowel movements. Denies history for liver disease, gallbladder infections and jaundice. GU: Denies blood in urine, burning sensation, incontinence, frequency, flank pain, incontinence, hesitancy and nocturia. Genital: Menstrual cycles are regular, denies clamping, bleeding after intercourse or before next periods, denies vagina discharge, STDs, itching, lumps and sores. Reports they use a condom with the husband during intercourse and hence not prone to infections. Musculoskeletal: Denies injury or trauma, extremity weakness, stiffness, pain and swelling. Hematologic/Endocrine: Reports type II diabetes mellitus. Denies weight gain or loss and intolerance to heat and cold. Denies excessive sweating, thyroid problems, polyuria and polydipsia. Denies ease of bruising and bleeding disorders. Psychiatric: Denies mood swings, concentration troubles, desire for self-harm or harm for others, nervousness, frequent happiness, panic attacks or hallucinations. Denies life stress that is excessive, loss of memory or nightmares. Neurologic: Denies extremity tingling or numbness, tremors, seizures and stroke history. Objective: General: The patient, a white female is well-mannered, groomed, slowly walks to the examination room with low facial mobility. She has a blunt expression. No facial hair distribution noted. Vitals: BP-120/8-, T-97.8, RR-18, P-80, O298%, Wt-149lbs, Ht-5’4”, BMI-25 Hair: Distributed evenly and thick. No infestations, breakage or dryness. The hair has a red color and is shiny. Skin: Warm, no bruises, no rashes, supple and is dry. Nails: Smooth without cyanosis or clubbing and are well manicured. Brisk finger pad capillary refill. Head/Neck: Atraumatic, Normocephalic with no visible injuries. Has a throbbing sensation in the right temporal region. Pain only concentrated in that region with no spread to other regions. No lesions or bumps. Moist and pink scalp. No tenderness or palpable lymph nodes, no sinus tenderness or enlargement of the lymph nodes. Palpable thyroid isthmus, no lobes felt, neck supple with the trachea midline. Eyes: PERRLA, EOMI, moist and pink conjunctiva, white sclera, no redness or drainage. Ears: Good acuity, no pinna or tragus abnormalities, no tenderness or ear canal inflammation, bilateral cerumen, intact and pearly white TM. Nose: Pink and intact turbinates, no discharge, nasal flaring, septal division with nares patent. Mouth/Throat: Moist and pink membranes, no exudates or redness, tonsils at pillars with the uvula midline. Tongue midline and good dentition. Lungs: Vesicular breath sounds, with no stridor, wheezes, rhonchi and crackles. Lungs resonant with a symmetric thorax. Heart: Left sternal border has a scratching noise, regular heart rhythm and rate, no splitting, no bruits in carotid strokes, no heaves, JVD, lifts or thrills. No opening snaps, gallops, rubs or murmurs. Breasts: Smooth, symmetric without nipple discharge or masses. Abdomen: Normal bowel sounds in all quadrants. No bruits in the abdomen. Abdomen non- distended, flat and soft. No tenderness in the abdomen upon palpation. No hepatosplenomegaly or palpable masses, no tenderness in the CVA. Lymph Nodes: Non-palpable inguinal, axilla, head, epitrochlear and neck lymph nodes. Extremities: Warm with no edema. No stasis, non-tender and supple calves. Motion at full range in all extremities. No enlarged joints or deformities. Genitals: Deferred on patient’s request. Rectum: Deferred Neurologic: Patient is cooperative, well oriented and alert. Effective in answering questions and following commands. Intact cranial nerves, Moves slowly due to pain. 2+ reflexes that are symmetric to the plantar reflexes. Assessment: Diagnosis: Migraine: A migraine is characterized by enlargement of the temporal artery. As a result of the enlargement, there is a stretch of nerves that are coiled around the temporal artery. These nerves will in turn release chemicals that can lead to pain, inflammation or further enlargement of the artery (McCance, 2015). Further growth of the artery leads to more pain. Differential Diagnosis: Cluster Headache: This is intense pain that attacks at night and is prevalent at one side of the head or side of the eye. It occurs spontaneously lasting for weeks or months. The attacks are also frequent (Bickley, 2014). The condition was ruled out since the headache was not spontaneous and severe. Additionally, the pain had only lasted for a few days. Viral Meningitis: This is an inflammation caused by a virus in the meninges. The major symptoms include nausea, sensitivity to bright light, headache and lethargy. The major cause of the condition is non-polio enteroviruses and herpes simplex virus (McCance, 2015). The patient does not have a history of an STD or viral infection and hence the condition was eliminated. Herpes Simplex Encephalitis: This refers to a brain inflammation resulting from a viral infection. The symptoms include weakness or fatigue, fever, joint aches and head ache. The patient did not have any viral infections, weakness, joint aches or fever (Uphold & Graham, 2013). Plan: 1. The patient should take an oral dose of 5mg Timilol twice a day to alleviate the pain. Additionally, the drug is also taken as a preventive measure to reduce severity in cases of recurrence. In case of a spontaneous onset, 1.25-2.5 mg Zomig taken orally will be effective in reducing the pain in the shortest duration of 2-3 hours (McCance, 2015). 2. Patient should be educated on the presentation of the migraine and the appropriate measures she should take in cases of occurrence. 3. The patient should report back to the health facility in cases that the headache becomes severe after medication. References Bickley, L. S. (2014). Bates’ Guide to Physical Examination and History Taking (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. McCance, K. L., & Huether, S. E. (2015). Pathophysiology: the biologic basis for disease in adults and children (6th ed.). Maryland Heights, MO: Mosby Elsevier. Uphold, C. R., & Graham, M. V. (2013). Clinical Guidelines in Family Practice (4th ed.). Gainesville, FL: Barmarrae Books. [Show More]

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