WK9Assgn 1 soap note PDF

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week 9 SOAP note for Tina Jones related to new hire med assess...

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Episodic/Focused SOAP Note Template

Week 9 Case Study Scenario: A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw. Patient Information: T.B., 28-year-old Caucasian Male Subjective: CC: “headache” HPI: T.B. is a 28-year-old Caucasian male presenting to the clinic today with complaints of a headache. The patient states that pain started intermittently 2 weeks ago but has progressed into constant pain over the last 3 days. He reports that his entire head hurts, but it is worse above his eyes and spreads through his nose, cheekbones, and jaws especially if he bends over or coughs. 

Location: Diffuse, all-over pain but is worse at the forehead, nose, cheekbones, and jaw/upper teeth.

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Onset: Intermittent for 2 weeks, constant for 3 days.

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Character: pounding dull ache with pressure

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Associated signs and symptoms: postnasal drip, raw feeling in throat, nausea, and pressure/pain in top teeth.

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Timing: varies but worse in the morning right after getting up

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Exacerbating/ relieving factors: lying flat, bending forward, and coughing make the pain worse. Tylenol and ibuprofen improve pain but do not relieve it.

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Severity: 6/10 pain scale

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Current Medications: 

Tylenol 500mg 2 tablets PO every 4-6 hours as needed for headache

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Ibuprofen 200 mg 3 tablets PO every 8 hours as needed for headache

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Zyrtec 10 mg 1 tablet PO daily

Allergies: 

Shellfish – anaphylaxis

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No known drug allergies

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No latex allergy

Patient Medical History: 1. Seasonal allergies 2. Kidney Stones Past Surgical History: 

Appendectomy – 2005

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Lithotripsy – 2014, 2018

Immunizations: 

Childhood immunizations up to date

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Tetanus vaccine – April 2020

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COVID vaccine – June 2021

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Flu vaccine – October 2020

Social History: The patient currently works as a state road crew employee. The patient spends most days outside in elements working. The patient is unmarried but is in a monogamous relationship with his live-in girlfriend for 7 years. The patient has no children, but his girlfriend is 6 months pregnant. The patient endorses wearing his seatbelt and has working smoke detectors in his home. The patient wears all appropriate safety equipment while working on the roadside. Patient and girlfriends’ families all live close by and is a positive support system.

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Family History: 

Mother – 50 y.o., living, Hypertension

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Father – 52 y.o., living, Hyperlipidemia

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Maternal Grandmother – 74 y.o., living, Hypertension, Hyperlipidemia, Breast Cancer

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Maternal Grandfather – Deceased, MI at 76 years old

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Paternal Grandmother – Deceased, CVA at 72 years old.

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Paternal Grandfather – Unknown

Review Of Systems: GENERAL: Denies weight loss, fever, chills, weakness, night sweats, or fatigue. HEENT: Reports postnasal drainage and raw feeling in his throat. Reports itchy eyes after working outside all day as well as increased “eye crusties” upon wakening in the am. Denies visual loss, blurred vision, double vision, or yellow sclerae. Denies ear pain or discharge but states that he occasionally feels ears pressure especially first thing in the morning over the last few days. . Denies hearing loss. Pt endorses facial pain and pressure around the eyes and through his cheeks. SKIN: Denies rash or itching. CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema. RESPIRATORY: Denies shortness of breath. Reports he coughs sometimes if he has increased nasal drainage or after lying down. GI/GU: Denies anorexia, vomiting, or diarrhea. No abdominal pain or blood in the stool. Reports intermittent nausea with increased nasal drainage. Denies urinary symptoms. Reports no changes in bowel habits. Neurological: Denies 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 easy bleeding, or bruising.

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Lymphatics: No history of splenectomy. Denies having any enlarged lymph nodes Psych: Denies history of depression or anxiety. Endocrine: Denies reports of sweating, cold, or heat intolerance. No polyuria or polydipsia. Allergies: Denies history of asthma, hives, or eczema. Does report a history of seasonal allergies which he OTC allergy medications for daily. Objective: Physical Examination: General: T.B. is a well-developed, well-nourished, white male who presents for evaluation of headache. He is dressed age and weather-appropriate and is wellgroomed, interactive in the exam, and appears in no acute distress. Vital Signs: Temp: 99.1 BP 130/78 P 76 RR 18 02 sat: 98% on room air. Weight: 168lbs/Height: 5’6” BMI: 27.1 HEENT: Head: Full range of motion of neck and head, symmetric, with no lesions or evidence of trauma observed. Facial features are symmetric, with no tics, tremors, or drooping observed. Frontal and Maxillary sinus tender to palpation. Ears: Symmetric, patent, pearl grey tympanic membrane, no erythema present. Eyes: Clear sclera, no discharge, pupil equal and reactive to light Nose: Mild clear rhinorrhea noted, both naris patent, septum intact, no deviation, bleeding, or crusts noted. Pale, boggy mucosa. Throat: No swelling of tonsils noted, pink, no erythema or excaudate noted. Postnasal drainage is evident.

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Neck: Symmetric, trachea midline. No JVD. No palpable lymph nodes in the neck. Thyroid gland palpated, no gross abnormalities. Cardiovascular: Regular Rate and Rhythm, S1 and S2 present, no advantageous sounds noted. No peripheral edema.

Respiratory: Lung sounds clear in all fields, no advantageous sounds noted. Neurological: Answers question appropriately, oriented to person, place, time, and situation. Pupils are equal and reactive to light. Grip strength equal both hands, face symmetric. Short-term and long-term memory intact. Headache rated 7/10 on the pain scale. Diagnostics: No diagnostic testing is generally needed for acute sinusitis. Treatment plans are developed based on subjective and objective data. If the condition does not clear promptly or becomes recurrent, the following diagnostic studies could be completed along with a referral to an allergy specialist: Nasal smear/nasal scraping: look for eosinophils that would confirm allergic rhinitis (Malmberg & Holopainen, 2007). Imaging studies: X-ray is less sensitive than CT, so specialists usually order radiographic imagining. Imaging studies determine if there are problems with the nasal anatomy or the presence of polyps or mucosal thickening that would require surgical intervention to improve a patient's chronic symptoms. The specialist will also do in-office exams such as sinus aspiration, nasal endoscopy, and skin allergy testing to determine the exact cause to help make a specific treatment plan for each patient.

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Assessment: #1 Acute Sinusitis: Acute sinusitis is suspected due to no fever, rash, or pain in facial joints with movement. Pertinent positives to this care include rhinorrhea, facial pain on palpation, pain in upper teeth, and discomfort when bending over. The cases of acute sinusitis seem to spike in the winter months. The patient's symptoms fit the criteria of this diagnosis. #2 Allergic Rhinitis: This is suspected with recurrent clear watery discharge that partners with an increase in seasonal allergy symptoms. This causes short and intense periods of nasal inflammation, swelling, which can cause headaches and pressure. #3 Rhinitis medicamentosa: This type of congestion is caused by long-term intranasal decongestants generally used for seasonal allergies. Chronic use will cause vasoconstriction causing constant pressure and congestion. This condition is ruled out based on a review of medication records and evaluating if the patient has been using any nasal sprays. #4 Medication rebound headache: This is a chronic daily headache associated with a decrease in certain medications or caffeine intake. The pain is generally diffuse and can be pinpointed to starting within hours of the last use of the substance. This has also been ruled out by the evaluation of medication records and no changes in patient intake. #5 Migraine without aura: This is a common disorder related to headache complaints. These types of headaches are generally unilateral, and patients present stating that their head is throbbing. Associated symptoms include photophobia, phonophobia, nausea, and vomiting (Hansen & Charles, 2019). All signs were ruled out in our ROS and exam.

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

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References Ball RN DrPH CPNP, Jane W., Dains DrPH JD RN FNP-BC FNAP FAANP, Joyce E., Flynn MD MBA MEd, John A., Solomon MD MPH, Barry S., Stewart MD MS MBA, Rosalyn W., & Stewart MD MS MBA, Rosalyn W. (2018). Seidel's guide to physical examination: An interprofessional approach (mosby's guide to physical examination) (9th ed.). Mosby. Hansen, J., & Charles, A. (2019). Differences in treatment response between migraine with aura and migraine without aura: Lessons from clinical practice and rcts. The Journal of Headache and Pain, 20(1). https://doi.org/10.1186/s10194-019-1046-4 Malmberg, H., & Holopainen, E. (2007). Nasal smear as a screening test for immediatetype nasal allergy. Allergy, 34(5), 331–337. https://doi.org/10.1111/j.13989995.1979.tb04375.x Medication overuse headaches - symptoms and causes - mayo clinic. (2020, December 8). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/medicationoveruse-headache/symptoms-causes/syc-20377083 Shrestha, M., Ghartimagar, D., Ghosh, A., & Jhunjhunwala, A. (2020). Sensitivity of sinus radiography compared to computed tomogram: A descriptive crosssectional study from western region of nepal. Journal of Nepal Medical Association, 58(224). https://doi.org/10.31729/jnma.4824 Sullivan, D. D. (2018). Guide to clinical documentation (3rd ed.). F A Davis. Varshney, J., & Varshney, H. (2015). Allergic rhinitis: An overview. Indian Journal of Otolaryngology and Head & Neck Surgery, 67(2), 143–149. https://doi.org/10.1007/s12070-015-0828-5

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Wahid, N. B., & Shermetaro, C. (2021, September 9). Rhinitis Medicamentosa. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK538318/ Worrall, G., MB BS MSc FCFP. (2011, May). Acute sinusitis. The National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093592/

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