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SOAP NOTE # 1 MIGRAINE W/O AURA, NOT INTRACTABLE

PATIENT INFORMATION

Encounter date: 05/16/2024.

Name: K.M.O.

Age: 25 years old.

Race: White.

Ethnicity: Hispanic.

Gender at Birth: Female.

Gender Identity: Female.

Marital State: Single.

Language: Spanish

Allergy(s): NKDA

Current Medication(s): Analgesic OTC. Ibuprofen 200 mg tabs: 400 mg orally every 4-6 hours as needed for pain.

Past Medical History: Denies.

Immunizations: Up to date. Flu (12/2023).

Surgical History: Appendectomy 15 years ago.

Social History: Alcohol: occasionally.

Drugs: denies use of illicit/street drugs

Smoking: denies smoke.

Exercise: 2-time aerobic exercise for week.

Family History: Mother: hypercholesterolemia.

Father: Arterial hypertension.

SUBJECTIVE DATA:

CC: “Doc. I have had a terrible headache and nausea for the last 3 days.”

HPI: K.M.O. is 25 years old, female patient with personal history of headaches with no defined diagnosis. It usually relieves with OTC medication. Today she comes to the office because she’s been having a headache for the past 3 days which has been presented in an unusual way. It is almost daily, more intense, reaching 7 on a scale from 0 to 10. Its characteristics are similar: dull, throbbing, located on the right side of the skull with numbness in the face, is accompanied by photophobia, discomfort at noises, nausea, and vomiting. It has been some relief with Ibuprofen 400 mg orally or sleeping a couple of hours, however, the pain can recur in the day. Do not recognize symptoms to warn her of the next presence of pain. Do not complain about pain at this time. No fever, chills, or other symptoms.

Review of Systems (ROS):

General: Denies any weight change, fever, chills, fatigue, night sweats, or energy level.

Cardiovascular: Denies any chest pain, palpitations, chest tightness, orthopnea, or edema.

Skin: Denies delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles.

Respiratory: No cough, no wheezing, no short of breath. Denies pneumonia hx, TB.

Eyes: Denies blurring, visual changes of any kind.

Gastrointestinal: No loss of appetite, no abdominal pain. No vomiting, no constipation. No documented history of hepatitis, hemorrhoids, eating disorders, ulcers, and black or tarry stools.

Ears: No ear pain, denies any ear hearing loss, ringing in ears, or discharge.

Genitourinary/Gynecological: No urgency, frequency burning, or change in color of urine. No sexual activities in the last three months. No STDs. Denies vaginal discharge.

Nose/Mouth/Throat: Denies any sinus problems, dysphagia, nose bleeds or discharge, hoarseness, throat pain.

Musculoskeletal: Denies any back pain, joint swelling, stiffness or pain, fracture.

Breast: Denies lumps, bumps, or changes.

Neurological: History of headache usually controlled with OTC analgesics. In the last two weeks the pain has become more intense and frequent, almost daily, which is not usual. Its characteristics are similar: dull, throbbing, located on the left side of the skull with numbness in the face, is accompanied by photophobia, discomfort at the noise, nausea, and vomiting. She denies symptoms that precede pain. Alleviate something with painkillers or sleeping for a few hours. Denies syncope, seizures, transient paralysis, weakness, paresthesia, blackout spells.

Heme/Lymph/Endo: No history of blood transfusion, night sweats, swollen glands, increased thirst, increased hunger, cold or heat intolerance.

Psychiatric: Denies depression, anxiety, suicidal ideation/attempts, or previous dx. No sleeping difficulties.

OBJECTIVE

Weight 175 lbs.

BMI 28.3

Temp 98.6 F

BP 130/80 mmhg

Height 5’ 3 in

Pulse 78 bpm

Respiratory 18

Sat O2: 99%

Pain: 8 (scale 0-10)

General Appearance: The patient is alert, quiet and well dressed. She appears well hydrated and well nourished.

Skin: Adequate color for his race, warm, dry, clean, and intact. There is no cyanosis of her skin, lips, or nails. There is no diaphoresis noted. Good skin turgor on examination.

HEENT: Patient’s head is normally cephalic. Her red reflexes are present bilaterally; and the pupils are equal, round, and reactive to light. Normal fundoscopy. There is no ocular discharge noted. External ear reveals that the pinnae are normal, and there is no tenderness to touch on the external ears. On otoscopic examination, both tympanic membranes (TM) are gray, in normal position, with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the TM. Both nostrils are patent. There is no nasal discharge, and no nasal flaring. Mucous membranes are noted to be moist. Teeth in good repair, gums pink, no abnormalities noted. There are no lesions noted in the oral cavity. Posterior pharynx: pink, no secretions. The neck is supple and able to move in all directions without resistance. No cervical nodes.

Cardiovascular: Regular rate and rhythm. S1 normal, S2, normal, no murmur. No clicks, no rubs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema. No cyanosis.

Respiratory: Symmetric chest walls. Respirations regular, no labored, no intercostal retractions; percussion normal; auscultation: no rales, no crackles, no wheezing, no rhonchi. No nasal flaring.

Gastrointestinal: BS active in all the four quadrants. Abdomen soft, no tender. No hepatosplenomegaly.

Rectal exam: not performed.

Breast: Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.

Genitourinary: Exam not performed.

Musculoskeletal: Full ROM seen in all 4 extremities as patient moved about the exam room. Muscular strength conserved in all 4 limbs.

Neurological: Speech clear. Tone well. Posture erect. Balance stable; gait normal. No abnormal reflex. No sensitive abnormalities.

Psychiatric: No signs / symptoms of anxiety, depression. Adequate behavior in the office.

Lab Tests ordered: CBC, Sedimentation rate, Glucose level, Thyroid stimulating hormone,

Other tests: Fundus examination, Electroencephalogram (EEG), Computed tomography

ASSESSMENT FINDINGS AND PLAN

Differential diagnoses:

1) Frontal sinusitis (ICD10 J01.10): It is inflammation or infection of the sinuses located just behind the eyes and in the forehead. If the frontal sinuses are inflamed or infected, they cannot drain mucus efficiently, and this can make breathing difficult. It can also lead to a feeling of increased pressure around the eyes and forehead. The symptoms of frontal sinusitis are tiredness, fever, muscle aches, nasal discharge, a feeling pressure behind the eyes, headache and sore throat.

2) Intracranial hemorrhage (ICD10 CM I62.9): Onset of symptoms of intracerebral hemorrhage is usually during daytime activity, with progressive (i.e., minutes to hours) development of the following: Sudden headache, alteration in level of consciousness, nausea and vomiting, seizures, and focal neurological deficits.

3) Giant Cell Arteritis (Temporal Arteritis) (ICD10 M31.6): Common signs and symptoms of GCA reflect the involvement of the temporal artery and other medium-sized arteries of the head and the neck and include headache, visual disturbances (diplopia, scotomas, ptosis, blurred vision, and loss of vision), jaw claudication, neck pain, and scalp tenderness. Constitutional manifestations, such as fatigue, malaise, and fever, may also be present. GCA should always be considered in the differential diagnosis of a new-onset headache in patients 50 years of age or older with an elevated erythrocyte sedimentation rate.

Primary diagnosis:

MIGRAINE W/O AURA, NOT INTRACTABLE, W/O STATUS MIGRAINOSUS (ICD10 G43.009): Our patient presented to the office with a clinical picture of headache that already has a history, but no definitive diagnosis. The pain has worsened in the last two weeks. The gender of the patient, the characteristics of the pain, the intensity, and the associated symptoms described in the differential diagnosis strongly suggest this diagnosis, in addition the patient denies symptoms or signs that precede the installation of the pain; therefore, it is the type of migraine without auras. The patient does not have a family history of this disease, but that this does not deny the diagnosis. The results of the indicated studies can confirm that the pain is not attributable to other causes.

Plan of treatment:

-Topiramate tabs 25 mg: twice a day orally.

-Almotriptan tabs 6.25 mg: orally daily during crisis.

Patient education including preventive care and anticipatory guidance:

-Education about the utility of and limits for acute medication and the potential for development of Medication Overuse Headache (MOH), so, appropriate prevention is important by lowering frequency of headaches that should help prevent MOH.

-Medication side effects.

-Education about the identification of triggers and relief: Regularity of regimen with regard to meals, hydration, sleep, and stress.

Referral:

Follow-up appointment with detailed plan:

– To review test results in five days.

– One month in the clinic, once evaluated by specialists. If symptoms worsen, or appear new symptoms return after.

References:

Estemalik, E., & Tepper, S. (2019). Preventive treatment in migraine and the new US guidelines. Neuropsychiatric Disease and Treatment, 9, 709–720.

Loder, E., Burch, R., & Rizzoli, P. (2020). The 2020 AHS/AAN guidelines for prevention of episodic migraine: A Summary and comparison with other recent clinical practice guidelines. American Headache Society.

Journal of Isfahan University of Medical Sciences, 17(6), 508–512. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3634285/.

Weatherall, M. (2019). The diagnosis and treatment of chronic migraine. Therapeutic Advances in Chronic Disease, 6(3), 115–123.

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