nur 600 assignment 11 2 writing a soap note

Sample Answer

Patient Information

• Initials D.P
  
• Age 23 years
  
• Sex Male
  
• Race African American
  
• Subjective History
  
• CC “Regular headaches.”
  

HPI

D.P is a 23-year-old AA male patient who presents with complaints of headaches that began eight days ago. He states that the headaches are intermittent and diffuse all over the head. The pain occurs for about 10-30 minutes.

The headache is described as a throbbing pain that has the greatest intensity and pressure above the eyes. He states that the pain spreads to the nose, cheekbones, and jaw. The headache is aggravated by activity and bending over and, to some extent, relieved by rest and taking Tylenol.

He denies experiencing nausea, vomiting, photophobia, or phonophobia associated with the headache. He rates the headache as 5/10 on the pain scale. D.P. reports that the headache often interferes with his activities.
Current Medications OTC Motrin 400 mg PRN to alleviate headaches.
Allergies Allergic to smoke and air sprays, causing sneezing. No known drug allergies.

PMHx D.P. has a history of Chronic sinusitis.

Social Hx D.P. is an intern at an Insurance firm, and he graduated four months ago with a Bachelor’s in Finance. He lives in the college hostels while in school and with his parents and two younger siblings on holidays. His hobbies include reading novels, writing articles, and painting.

He is financed by his two parents and gets some money from his part-time job. K.M. admits taking alcohol, 3-4 beers on weekends, but denies smoking or using other illicit drugs.

Family Hx Paternal grandfather had pancreatic cancer. Father has Diabetes. Sibling alive and well.

ROS

• General Denies fatigue, weight changes, fever, or chills.
  
• HEENT Positive for headache, facial pain, facial pressure, and rhinorrhea.
• Denies visual changes, photophobia, phonophobia, hearing loss, loss of taste, or swallowing difficulties.
  

Neck No neck pain or stiffness.

• Skin No skin color changes, itching, rashes, or lesions.
  
• Cardiovascular No edema, palpitations, chest pain, or exertional dyspnea.
  
• Respiratory No cough, sputum production, chest pain, or shortness of breath.
  
• Gastrointestinal No appetite changes, epigastric pain, abdominal pain, bowel changes, or rectal bleeding.
  
• Genitourinary No penile discharge, dysuria, blood in urine, or urinary urgency/frequency.
  
• Neurological Positive for headache. No dizziness, black spells, altered conscious levels, or tingling sensations.
  
• Musculoskeletal No muscle pain, back pain, joint pain, or stiffness.
  
• Hematologic No history of bleeding gums, anemia, or blood transfusion.
  
• Lymphatic’s Negative for lymph node enlargement.
  
• Psychiatric No anxiety or depressive symptoms.
  
• Endocrinologic No heat/cold intolerance, increased urine production, acute thirst, or excessive hunger.
  
• Allergies Allergic to smoke and air sprays.
  

Objective History

• Physical Exam
  
• Vital Signs BP- 118/76 mm Hg; Resp- 22; PR- 88; Temp- 98.78 F
  
• Weight- 137 lbs.; Height- 5’5; BMI- 22.8
  

General

The client is well-groomed and appropriately dressed for the weather. He is alert and in no acute pain or distress. Oriented to person, place, and time; maintains eye contact and has clear speech.

HEENT

Head Atraumatic and normocephalic. Hair is black, well-distributed, with no scalp tenderness. Tenderness on the cheekbones and jawline. Eyes Sclera is white and conjunctiva pink.

PERRLA with no excessive lacrimation. Tenderness on the orbital area and frontal sinus are palpable. Ears T.M.s clear. Minimal pus present but with no ear discharge.

No mastoid bone inflammation. Nose Rhinorrhea with clear nasal discharge. Tenderness on the bridge of the nose. Throat Mucous membranes pink and moist. Tonsillar glands are non-erythematous.

Neck Full ROM of the neck. The trachea is midline. The thyroid gland is normal on palpation. Respiratory Respirations smooth, chest rise and falls in unison on inspiration and expiration. Lungs clear on auscultation.

Cardiovascular No edema or jugular vein distension. Capillary refill- 2 seconds. S1 and S2 are present. Gallop sounds, systolic murmurs, and frictions rub absent. Neurological Speech is clear with normal volume and rate. C.N.s intact. Muscle strength 5/5.

Assessment

Differential Diagnoses

Sinus Headache Common symptoms of a Sinus headache include facial pain and pressure, nasal and sinus congestion, and headache. The headache is usually pulsating or throbbing and is moderate to severe. It usually occurs in the sinuses, the area of the cheeks above the maxillary sinus, the bridge of the nose above the ethmoid sinus, or the eyes above the frontal sinus (Maurya et al., 2019).

Sinus Headache is a presumptive diagnosis based on DP’s symptoms of throbbing, intermittent, diffuse, moderate headaches. Besides, the headache is aggravated by activity. He also has pressure above the eyes, nose, cheekbones, and jaw, where the sinuses are located.

Other pertinent positive findings include rhinorrhea, nasal drip, tenderness over sinus areas, palpable sinuses, and a history of chronic sinusitis.
Cluster Headache It manifests with headache attacks that are usually severe or very severe and strictly unilateral pain occurring in the orbital, supraorbital, or temporal regions (De Corso et al., 2018).

It lasts 15 to 180 minutes and can occur once to 8 times a day. This is a differential diagnosis based on the patient’s symptoms of headache, pain in the orbital, supraorbital, or temporal regions, and nasal congestion. However, DP has a diffuse, bilateral headache, ruling out a primary Cluster headache diagnosis.

Episodic Tension-Type Headache (TTH) Episodic TTH is a differential diagnosis based on pertinent positive findings of the diffuse headache of moderate intensity. Pertinent negative findings include a non-pulsating headache and scalp and neck tenderness (García-Azorín et al., 2020). Besides, the patient’s headache is aggravated by activity, which rules out TTH as a possible diagnosis.

Plan

• Medication plan Tylenol 500 mg PRN.
  
• Saline nasal spray to thin mucus.
  
• Phenylephrine nasal decongestant alleviates sinus swelling and drains mucus (Maurya et al., 2019).
  

Non-pharmacologic Warm compressions on tender areas of the face.
Health Education The patient will be educated on regular physical exercises, stretching, massage, balanced meals, and adequate sleep to prevent frequent headaches.

Massage helps to relieve tight muscles in the back of the head, neck, and shoulders, alleviating headaches (May, 2018).
Consultation Otolaryngology consultation if the headache worsens.

References

• De Corso, E., Kar, M., Cantone, E., Lucidi, D., Settimi, S., Mele, D., Salvati, A., Muluk, N. B., Paludetti, G., & Cingi, C. (2018). Facial pain sinus or not? Acta otorhinolaryngologica Italica organo ufficiale Della Societa italiana di otorinolaringologia e chirurgia cervico-facciale, 38(6), 485–496. https //doi.org/10.14639/0392-100X-1721
  
• García-Azorín, D., Farid-Zahran, M., Gutiérrez-Sánchez, M., González-García, M. N., Guerrero, A. L., & Porta-Etessam, J. (2020). Tension-type headache in the Emergency Department Diagnosis and misdiagnosis The TEDDi study. Scientific reports, 10(1), 2446. https //doi.org/10.1038/s41598-020-59171-4
  
• Maurya, A., Qureshi, S., Jadia, S., & Maurya, M. (2019). “Sinus Headache” Diagnosis and Dilemma?? An Analytical and Prospective Study. Indian journal of otolaryngology and head and neck surgery official publication of the Association of Otolaryngologists of India, 71(3), 367–370. https //doi.org/10.1007/s12070-019-01603-3
  
• May A. (2018). Hints on Diagnosing and Treating Headache. Deutsches Arzteblatt international, 115(17), 299–308. https //doi.org/10.3238/arztebl.2018.0299