MSN 572 Week 6 SOAP Note

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MSN 572 Week 6 SOAP Note

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ID:

• Client’s Initials: M.H. Age: 69 DOB: July 9, 1954 
• Race/ Ethnicity: Asian Gender: Male
• Arrived at the clinic accompanied or alone? Alone, who is the historian? Patient

Subjective 

CC: 

Experiencing severe headaches might result in feelings of nausea and vomiting.

HPI:

During today’s appointment visit, M.H. provided a comprehensive account of the debilitating headaches that began approximately two months ago. The duration of his headaches often spans from three to five days per month. Symptoms include hemiparesis, nausea, aphasia, photophobia, and visual impairment. He derives comfort from sleeping in darkness; exposure to light from screens is a stimulus. Despite using ibuprofen, her symptoms have only exhibited a slight amelioration—no known allergies.

ROS: 

General: Normal health, no fatigue or fever.

Head: The scalp’s distribution and texture are expected, and a physical examination does not detect any evidence of redness, cysts, or tumors. 

Eyes: The Pupil’s Equal, Round, Reactive to Light and Accommodation (PERRLA) response is also affirmative. The lids, conjunctiva, and sclera showed no abnormalities. 

Ear: The ear displayed no visible abnormalities, swelling, or discomfort.

Throat/Neck: The throat examination showed no visible symptoms of edema, stiffness, or lymphadenopathy in the patient’s neck or throat area. 

Musculoskeletal: Pain in the right wrist.

Neurological: Headache.

Past Medical History:

• Medical problem list: No previous health issues. 

• Preventative care: None
• Surgeries/ Hospitalizations: Underwent a cholecystectomy at the age of 27, an appendectomy at the age of 14, and a partial hysterectomy at the age of 34.
• LMP, pregnancy status, menopause, etc. for women: Not applicable.

Allergies:

NKDA

Medications: 

To ease discomfort, consume three to four gel tablets of ibuprofen, each containing 200 mg, at six to eight-hour intervals.

Family History: 

The exact reasons for death for both the maternal and paternal grandparents are undisclosed in the family lineage. The mother, aged 94, experiences hypertension and migraines, while the father, aged 97, faces challenges with diabetes and hypertension. There is no significant familial medical history.

Social History:

• Sexual history and contraception/protection: None
• Chemical history (tobacco/alcohol/drugs): Smokes twice a week.
• Diet and Exercise: Moderate exercise.
• Spirituality/ Health Practices: None
• School/work: Truck driver.
• Living arrangements: Dormitory. 

Other: They were in a faithful and exclusive marriage for 40 years. Abstain from smoking and limit alcohol consumption to occasional wine drinking. Oversees the company’s operations in the capacity of a truck driver. Regularly participates in athletic pursuits such as swimming, kayaking, and hiking while strictly following a vegetarian diet. He asserts that he consistently obtains 8 to 9 hours of sleep each night without experiencing any difficulty in relaxing, despite experiencing lengthy anxiousness while working.

Objective

Vital Signs:   

• H.R.: 68 
• B.P.: 125/80   
• Temp: 97.8 F
• R.R.: 16 /min    
• SpO2: 98% on R.A.       
• Pain: 6/10  

Height: 5’9’’ Weight: 160 lb        

• Labs, radiology, or other pertinent studies: Not reported.

Physical Exam:

Mental Status: Responds appropriately to every question, displaying thorough comprehension.

Mental state: Sufficient degree of self-awareness.

Orientation: Focused on the here and now, on the person, on the place, and the event.

Speech: The speaker uses natural, easy-to-understand language.

Memory: Item recall is 3 out of 3 at 5 minutes, and both recent and distant memories are intact.

Validation: Confirmed and unchanged assurance.

Nerves:

CN I (Olfactory): Smells normally

CN II (Optic): The visual fields display a whole confrontation. Images taken under the fundus microscope reveal regular anatomical features, including a sharply bordered optic disc with a disc-to-cup ratio 1:3 and normal blood vessels devoid of abnormalities such as A.V. nicks or cotton wool bodies. Pupils are 4 mm in diameter, round, and equally responsive to light and accommodation on both sides. The eyesight in both eyes is flawless.

CN III (Ocular Motor): A full range of vision is present in both eyes, and nystagmus is absent. There is a normal, unaltered, and mutually agreed-upon pupillary reflex.

CN IV (Trochlear): Both eyes can usually see when looking forward and to the side. Nystagmus is absent.

C.N. V: Both eyes can usually see when looking forward and to the side. Nystagmus is absent.

CN VI (Abducens): There is no nystagmus, and both sides’ lateral fields of vision are impaired.

CN VII (Facial): In this face region, you can see a scrunched brow, a tested smile, enlarged cheeks, and an unbroken upper and lower set of eyebrows.

The brain’s nerves are unharmed, and a gag reflex is present.

CN VII (Hypoglossal): The test shows a midline tongue when the patient moves laterally and protrudes. Showing no movement, the person remains perfectly still while pressing their tongue against their cheek.

Assessment

Differential Diagnoses:

1. Migraine Headache (G43-909) (Nowaczewska et al., 2020).
2. Tension Headache (G44-209) (Ashina et al., 2021).
3. Headache (Unspecified) (R51.9) (Seyed Hossein Abtahi et al., 2023).

Primary Diagnosis: 

Due to a notable familial predisposition to migraines, the patient is presently experiencing a migraine headache. Migraine headaches exhibit a strong genetic predisposition (Nowaczewska et al., 2020). The patient is at increased susceptibility to developing migraines as a result of the familial lineage of other individuals who have migraines. The symptoms indicate migraines, although it is plausible for tension headaches or another type of headache to coexist (Nowaczewska et al., 2020).

References

Ashina, S., Mitsikostas, D. D., Lee, M. J., Yamani, N., Wang, S.-J., Messina, R., Ashina, H., Buse, D. C., Pozo-Rosich, P., Jensen, R. H., Diener, H.-C., & Lipton, R. B. (2021). Tension-type headache. Nature Reviews Disease Primers, 7(1). https://doi.org/10.1038/s41572-021-00257-2

Fisher, M., Aher, A., Araga, M., & Franks, B. (2023). Patient factors in the dose selection of oral sumatriptan for acute migraine: a post hoc analysis of two randomized controlled studies. Pain and Therapy. https://doi.org/10.1007/s40122-023-00511-3

Nowaczewska, M., Wiciński, M., & Kaźmierczak, W. (2020). The ambiguous role of caffeine in migraine headache: from trigger to treatment. Nutrients, 12(8), 2259. https://doi.org/10.3390/nu12082259

Seyed Hossein Abtahi, Fatemeh Esfahanian, Akbari, M., Peyman Roomizadeh, & Neshat, S. (2023). Headache—a challenge across medical students’ life: a systematic review and meta-analysis. Acta Neurologica Belgica, 123(3), 785–801. https://doi.org/10.1007/s13760-023-02274-2

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