Running head: WEEK 9 DISCUSSION 1

Episodic/Focused SOAP Note

Author’s Name

Institutional Affiliation
WEEK 9 DISCUSSION 2

Episodic/Focused SOAP Note

Patient Information

The patient is a 20 year old male of Caucasian decent who is complaining that he is experiencing

intermittent headaches. Although the headaches have diffused all over his head, the patient

experiences the greatest pressure and intensity above the eyes, spreading across the nose, jaw and

checkboxes.

Initials: S

Patient: B.J

Age: 20

Race: Caucasian

CC: Intermittent headache

HPI: 20-year-old White male is experiencing a diverse range of symptoms namely intermittent

headaches which have diffused all over his head for the past 1 month. Moreover, the patient

experiences the greatest pressure and intensity above the eyes, spreading across the nose, jaw and

checkboxes.

Location: Patients head just above the eyes and across the nose, eyes, jaws and cheekbones.

Onset: Intermittent headaches for 1 month

Character: Begins with a dull headache which gradually intensifies into a throbbing headache.

Associated signs and symptoms: Significant pressure and intensity above the eyes, spreading

across the nose, jaw and check bones.

Timing: Intermittent

Exacerbating/ relieving factors: br8ight light, noise

Severity: 8/10 pain scale

Current Medications: Ibuprofen 400 mg PO

Allergies: No known allergies

PMHx: Was vaccinated 2 years ago. Underwent appendectomy at the age of 10 years.

Soc Hx: The patient has a number of hobbies such as playing football and traveling

Fam Hx: Mother died at the age of 78 from Coronary heart disease.

ROS:

GENERAL:  No fever or chills, no weight loss and No recent case of illness

HEENT:  No visual loss, No hearing loss or blurred vision

GENITOURINARY: No urinary problem, No burning urination

NEUROLOGICAL:  Intermittent headaches

MUSCULOSKELETAL:  No muscle, joint pain and back pain.

LYMPHATICS:  No enlarged nodes, patient denies history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety

ALLERGIES:  No allergies

O.

HEENT:  No visual loss, No hearing loss or blurred vision

GENITOURINARY: No urinary problem as well as No burning urination

NEUROLOGICAL:  Intermittent headaches

MUSCULOSKELETAL:  No report of muscoskeletal problem

LYMPHATICS: No enlarged nodes, patient denies history of splenectomy.

Diagnostic Results

There are a number of diagnostic tests which will be performed to determine the appropriate

diagnosis of the condition some of which include the following:

Computed Tomography (CT) Scan: Firstly, a Computed Tomography (CT) Scan will be

performed on the patient to help detect or rule out the possibility of an intracranial disease as the

course of the condition. This will particularly be carried out at the onset of another intermittent

headache or when abnormal neurological findings have been detected (Schoenen & Sándor,

2014).

Erythrocyte Sedimentation Rate (ESR): This diagnosis test will be carried to determine

whether there is an elevation of the erythrocytes which indicates the possibility of an

inflammation. This is done to rule out arteritis as the cause of the intermittent headache in the

patient.

Complete blood count (CBC): This will be done to determine the potential presence of anemia

or blood dyscracias in the patient as a cause of the patient’s condition. A complete blood count

(CBC) is an important blood test that is normally utilized to help in the assessment of the

general health of the patient as well as help in the diagnosis of various other illnesses which may

contribute to the patient’s condition. Some of the aspects measured during complete blood count

include the oxygen-carrying red blood cells.

Lumbar Puncture test: The diagnosis test will be performed in order to check for the presence

of cerebrospinal fluid pressure such as by detecting altered components such as protein,

lymphocytes and glucose levels. This is critically important in detecting the likelihood of an

infection of the central nervous system.

Differential Diagnoses

1. Sinusitis

One of the possible conditions which are likely to cause the patient’s condition is Sinusitis.

The condition is primarily characterized by an inflammation of the sinus lining tissues which

then causes intermittent headache among other symptoms such as running nose and facial pain

(Huang, 2018). Although this is a possible diagnosis, the absence of the other symptoms such as

respiratory symptoms, running nose and facial pain rules it as the cause of the patient’s

condition.

2. Tension-Type Headache (TTH)

Another potential diagnosis of the patient’s condition is Tension-Type Headache (TTH).

The condition is often characterized by mild to severe ache that feels like a tight band around the

head is common. A tension headache can be caused by a variety of reasons, including stress,

insufficient sleep, and bad posture. The predominant symptom is headache discomfort on both

sides, which may be accompanied by muscular soreness. Generally, Tension-Type Headache

(TTH) is often related with muscle contraction but may also be caused by stress or depression.

3. Mixed Headache

There is also a high possibility that the patient may be suffering from a mixed headache.

The mixed headache condition is primarily characterized by the coexistence of two forms of

headaches namely migraine and muscular contractions in the patient. Despite the fact that both

entities have been widely researched as independent illnesses, there has been little study on the

mixed headache syndrome and its pathophysiology. However, this diagnosis can be ruled out by

the fact that the patient is not presenting symptoms of complaints of muscle contraction.
WEEK 9 DISCUSSION 6

4. Brain Tumor

There is a possibility that the patient’s condition may be caused by a brain tumor. A brain

tumor is often characterized by an abnormal cell growth or mass in the brain. This may be

benign (noncancerous) or cancerous (malignant). According to Langner & Kirsch (2015),

brain tumors may cause symptoms similar to those experienced by the patient because of the

pressure on the intracranial pressure caused when the tumor obstructs the flow of cerebral

spinal fluid thereby causing intermittent headache.

5. Bacterial Meningitis

The condition of the patient may also likely be caused by a Bacterial Meningitis. The

disease is mainly caused by a bacterial infection of the meningitis and is often characterized

by various symptoms such as intermittent headache among other symptoms like high fever.

Bacterial meningitis is a dangerous condition. In the United States, bacterium is widely

believed to be one of the most prevalent cause of bacterial meningitis among b0oth young

people and adults. Generally, the bacterium is often more likely to cause pneumonia, ear

infections, or sinus infections.

References
WEEK 9 DISCUSSION 7

Huang, H. H., Lee, T. J., Huang, C. C., Chang, P. H., & Huang, S. F. (2018). Non–sinusitis-

related rhinogenous headache: a ten-year experience. American journal of

otolaryngology, 29(5), 326-332.

Langner, S., & Kirsch, M. (2015). Radiological diagnosis and differential diagnosis of headache.

In RöFo-Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebenden

Verfahren (Vol. 187, No. 10, pp. 879-891.

Schoenen, J., & Sándor, P. S. (2014). Headache with focal neurological signs or symptoms: a

complicated differential diagnosis. The Lancet Neurology, 3(4), 237-245.