Focused SOAP Note
Patient Information:
D, 72-years old female.
S.
Chief Complaint (CC):
Debilitating headache and neck pain
HPI:
Dickson is a 72-year old female who comes to the clinic with a debilitating headache and neck pain. The patient complains that the problem is not new, but has worsened in the last week and currently it is affecting her vision. She denies of any visual or auditory hallucinations. The patient complains of dry eyes and vision problems. Typically takes 1 to 2 tabs of OTC Naproxen with ‘some help’. “Sleeping it off in a darkened room’ helps alleviate the headache. Rating the pain as 5/10.
Current Medications:
The current medication include Synthroid 100 mcg daily, HCTZ 12.5mg daily, Multivitamin daily, Aspirin 81 mg PO daily, and simvastatin 40mg.
Allergies:
NKDA
PMHx:
Hypertension, Hyperlipidemia, Osteoporosis
PSHx:
No information is available
Soc Hx:
No information is available.
Fam Hx:
No information is available.
ROS:
GENERAL:
The patient complains that her eyes are dry. Her visual acuity is 20/50 OU, 20/40 OD, 20/50 OS. The eyelids are erythematous and edematous with yellow crusting around the lashes.
HEENT:
Eyes: eyes are dry. Her visual acuity is 20/50 OU, 20/40 OD, 20/50 OS. She denies tearing and an itchy, burning sensation in both eyes. The eyelids are erythematous and edematous with yellow crusting around the lashes
Ears: No information is available.
Nose: No information is available.
Throat: No information is available.
SKIN:
No skin condition reported in the past.
CARDIOVASCULAR:
No chest pain, edema, or uncontrolled heart conditions. Diagnosed with hypertension and Hyperlipidemia but they are well-controlled using drugs.
RESPIRATORY:
No respiratory condition like nasal congestion is noted.
GASTROINTESTINAL:
No complaints of abnormal bowel movement, no nausea, vomiting or blood in the stool.
GENITOURINARY:
The patient does not complain of dysuria or polyuria or pain while passing urine.
NEUROLOGICAL:
No abnormal bowel and bladder control is noted. Debilitating headache. No dizziness or seizures.
MUSCULOSKELETAL:
No abnormalities noted or back pain.
HEMATOLOGIC:
The patient has no blood disorder or excessive bleeding.
LYMPHATICS:
No history of swollen lymph nodes.
PSYCHIATRIC:
No history of depression or stress. Patient denies suicidal thoughts or ideations.
ENDOCRINOLOGIC:
No abnormal sweating, excessive thirst or fever at night.
ALLERGIES:
NKDA
O.
V.S:
98.1 120/64 HR-72 20
Physical exam:
A physical examination shows that the eyelids are erythematous and edematous with yellow crusting around the lashes. Her visual acuity is 20/50 OU, 20/40 OD, 20/50 OS.
HEENT, CV, Respiratory, Musculoskeletal, Lymphatic, Allergies, and Diagnostic results:
The information from subjective and objective data shows the patient is unwell due to the debilitating headache.
Head: Normal head and neck movement. No bruises or swelling.
Ears: No erythema.
Eyes: Vision problems due to headache.
Nose: No nasal congestion or rhinorrhea.
Throat: No erythema or swelling and clear speech.
Neck: No swelling or palpable lymph.
Cardiovascular: Hypertensive.
Respiratory: Clear lungs and no adventitious sound.
Neurological: She is alert and oriented to person, partially oriented to place but is disoriented to time and place.
Diagnostic Results:
CXR—no cardiopulmonary findings. WNL 2.
CT head—diffuse Cerebral Atrophy
A.
Differential Diagnoses:
a) Cervicogenic:
Cervicogenic is a headache that develops in the neck, although a person feels pain in the neck. It is one of the secondary headaches caused by underlying conditions. Recent research has shown that cervicogenic headache is prevalent among individuals over 50 with headaches, with estimates ranging from 0.4% to 42% (Xu et al., 2023). Some of the underlying conditions include severe high blood pressure, neck injuries, and infections (Reiley et al., 2017). Others have damaged disc or movement that compresses the nerves around the neck. Some of the conditions’ treatments include active lifestyle, medication, possible surgery, and lowering the blood pressure (Reiley et al., 2017). The condition symptoms include pain around the eyes, a stiff neck, pain on one side of the neck, and headache with specific neck postures. The condition is chronic and may continue for months or years (Barmherzig & Kingston, 2019). Diagnosis of the condition involves manual examination techniques, diagnostic nerve blocks, and medical history evaluation.
Cervicogenic is the possible condition the patient is suffering from due to the similarities in the symptoms. Interestingly, recent studies have found that individuals with neck headaches demonstrate significantly reduced performance in craniocervical flexion tests, suggesting a potential diagnostic tool for cervicogenic headaches (Xu et al., 2023). This finding could be particularly relevant for our patient, given her age and symptom presentation.
b) Tension Headache:
Tension headache triggers diffuse, mild to moderate pain. The condition feels like a tight band around the head. The causes of the disease are not well-understood. It occurs at any age, and it is one of the most common types of headache (Eidlitz-Markus et al., 2017). Some of the causes include poor posture, inadequate sleep, and stress. It causes pain on both sides of the head. Some available treatments include pain relievers, stress reduction, and sleeping on good posture (Eidlitz-Markus et al., 2017). It causes dull itching head pain, a sensation of tightness on the forehead, tenderness on the scalp, or shoulder muscles. While tension headaches share some similarities with our patient’s symptoms, the localized nature of her pain and its association with neck issues suggest a different underlying cause.
c) Migraine headache
Migraine headache causes severe throbbing pain, usually on the side of the head. It is accompanied by vomiting, nausea, and extreme sensitivity to light (Mayans & Walling, 2018). The migraine attacks can last for hours or days. The pain can be so severe that it interferes with daily activities. The causes include emotional triggers such as stress, depression, anxiety, and excitement (Mayans & Walling, 2018). Hormonal changes can also trigger the condition, especially during menstruation. Dietary factors include eating certain types of food, alcohol, and caffeine. Menstrual changes are common among women, especially during pregnancy and menopause (Mayans & Walling, 2018). Taking contraceptives can worsen the condition. Patients take pain relievers, triptans, anti-nausea drugs, and opioid medication. Although our patient reports vision problems, the absence of typical migraine symptoms like nausea and light sensitivity makes this diagnosis less likely in her case.
Treatment Plan
Treatment for Cervicogenic involves targeting the cause of the pain in the neck. It varies depending on what works best for individual patients. Some of the best treatments include physical therapy and exercise, medication, and nerve blocks (Jafari et al., 2017). A recent study has revealed promising directions for cervicogenic headache management through repeated end-range movements, offering a potential new approach to treatment (Tufts University School of Medicine, 2023). Evidence-based practice shows that a continuous exercise regimen will generate quality results. Manual therapy of the condition involves massage, manipulation, and physical therapy. Treatment focuses on relieving pain or pressure on the joints (Jafari et al., 2017). The patient should also take medication such as tricyclic antidepressants and anti-epileptic drugs.
The patient should exercise daily while going for therapy three times a week. She should take medication daily to relieve the pain. It is essential to sleep in a good posture, avoid stress or high blood pressure (Jafari et al., 2017). The patient should take the medication for high blood pressure consistently to prevent complications. She should eat a balanced diet. It is crucial to avoid stressing activities such as lifting heavy objects.
Patient education involves avoiding activities that can trigger pain or stress on the neck or head. The patient should consult with a physician to assess if the blood pressure is stabilizing or worsening. She should continue taking medication for all the health conditions.
The treatment plan should involve referral to a psychiatrist or counselor to further evaluate the patient’s mental condition. Evidence-based practice shows that depression and stress can spike blood pressure, triggering headaches (Reiley et al., 2017). If the patient had a mental condition such as stress, they should see the counselor for several sessions until their mental health improves drastically. Recent research has also highlighted the potential benefits of non-pharmacological interventions, such as acupuncture and massage, in managing cervicogenic headaches (Liu et al., 2024). These complementary therapies could be considered as part of a holistic treatment approach for our patient.
Reflection
The assessment of the patient’s health condition shows that further information is required for a better evaluation. A medical history should be detailed to establish if some conditions could be causing pain. The patient should continue taking the medication and come back for an assessment to determine if the situation is improving, stabilizing, or worsening. Recent studies have emphasized the importance of a multidisciplinary approach in managing cervicogenic headaches, combining physical therapy, medication, and lifestyle modifications (Jull, 2023).
I learned various lessons during the assessment. One of the lessons is that underlying conditions can trigger pain in the head. For instance, severe blood pressure can cause a headache. The physicians’ responsibility is to ensure they evaluate the underlying conditions to determine the real causes of pain. I also learned that headaches could occur due to different reasons. Thus, the patient needs to come for therapy frequently after the first assessment to evaluate the progress. Some headaches can signal a severe condition that can lead to death or rapture of the blood vessels.
Patient education is essential for the treatment of conditions such as headaches. It is one of the approaches that change the lifestyle that can trigger a headache. For instance, poor sleeping postures, avoiding stress, and eating healthy can transform a patient’s health. I also learned that it is the responsibility of patients to provide adequate information about their health condition. The information is crucial in analyzing the condition a patient may be suffering from. Additionally, staying updated on the latest research in cervicogenic headaches has reinforced the importance of evidence-based practice in developing effective treatment plans tailored to each patient’s unique needs.
References
Barmherzig, R., & Kingston, W. (2019). Occipital neuralgia and cervicogenic headache: diagnosis and management. Current Neurology and Neuroscience Reports, 19(5), 20.
Eidlitz-Markus, T., Zolden, S., Haimi-Cohen, Y., & Zeharia, A. (2017). Comparison of comorbidities of migraine and tension headache in a pediatric headache clinic. Cephalalgia, 37(12), 1135-1144.
Jafari, M., Bahrpeyma, F., & Togha, M. (2017). Effect of ischemic compression for cervicogenic headache and elastic behavior of active trigger point in the sternocleidomastoid muscle using ultrasound imaging. Journal of Bodywork and Movement Therapies, 21(4), 933-939.
Jull, G. (2023). Cervicogenic headache. Journal of Manual & Manipulative Therapy, 31(5), 249-257.
Liu, Z., et al. (2024). Meta-Analysis of Acupuncture Treatment for Cervicogenic Headache. World Neurosurgery, 184, 277-285.
Mayans, L., & Walling, A. (2018). Acute migraine headache: treatment strategies. American Family Physician, 97(4), 243-251.
Reiley, A. S., Vickory, F. M., Funderburg, S. E., Cesario, R. A., & Clendaniel, R. A. (2017). How to diagnose cervicogenic dizziness. Archives of Physiotherapy, 7(1), 12.
Tufts University School of Medicine. (2023). Study Reveals Promising Directions for Cervicogenic Headache Management Through Repeated End Range Movements. Retrieved from https://medicine.tufts.edu/news-events/news/study-reveals-promising-directions-cervicogenic-headache-management-through-repeated-end-range-movements
Xu, Y., et al. (2023). Global trends in research on cervicogenic headache: A bibliometric analysis from 2000 to 2022. Frontiers in Neurology, 14, 1169477.
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Assessing, Diagnosing, and Treating Head, Neck, and Face Disorders
Head, neck, and face disorders are common, and thus you will likely care for elderly patients with these disorders. These conditions can significantly impact a patient’s quality of life and daily functioning. In your role as an advanced practice nurse, you must be able not only to correctly assess and diagnose patients but also help patients manage the disorder by planning necessary treatments, assessments, and follow-up care. This comprehensive approach ensures that patients receive holistic and effective care.
To prepare: Review the case study provided by your Instructor. This will help you understand the specific context and details of the patient’s condition. Reflect on the patient’s symptoms and aspects of disorders that may be present. Consider how these symptoms align with common clinical presentations of head, neck, and face disorders. Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case. This will involve integrating clinical guidelines and evidence-based practices into your decision-making process. Access the Focused SOAP Note Template in this week’s Resources. This template will guide you in systematically documenting the patient’s case.
The Assignment: Complete the Focused SOAP Note Template provided for the patient in the case study. This will help ensure that all relevant information is captured accurately. Be sure to address the following: Subjective: What was the patient’s subjective complaint? Understanding the patient’s perspective is crucial for accurate diagnosis and treatment planning. What details did the patient provide regarding their history of present illness and personal and medical history? This information can offer insights into potential underlying causes or contributing factors. Include a list of prescription and over-the-counter drugs the patient is currently taking. This is important for identifying potential drug interactions or contraindications. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. This comparison helps ensure that the medications are safe and appropriate for elderly patients. Provide a review of systems. This comprehensive review can help identify any additional symptoms or concerns that may need to be addressed.
Objective: What observations did you note from the physical assessment? Objective findings provide critical data for forming a differential diagnosis. What were the lab, imaging, or functional assessments results? These results can confirm or rule out potential diagnoses.
Assessment: Provide a minimum of three differential diagnoses. This step is essential for considering all possible explanations for the patient’s symptoms. List them from top priority to least priority. Prioritizing helps focus on the most likely and urgent conditions. Compare the diagnostic criteria for each, and explain what rules each differential in or out. This comparison helps refine the diagnosis based on clinical evidence. Explain your critical thinking process that led you to the primary diagnosis you selected. This reflection demonstrates your clinical reasoning skills. Include pertinent positives and pertinent negatives for the specific patient case. These details help support or refute each potential diagnosis.
Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. A well-structured plan ensures comprehensive care for the patient. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. This documentation is crucial for continuity of care and patient safety. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. This discussion helps in preventing future complications and promoting overall health. Finally, include a reflection statement on the case that describes insights or lessons learned. Reflecting on the case can enhance your clinical practice and professional growth.
Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. This evidence supports the clinical decisions made in the case. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Staying updated with current standards ensures that the care provided is based on the latest research and best practices. Follow APA 7th edition. Proper citation is important for academic integrity and professionalism.
Case study: 72-year-old Dickson, a female patient seen in Office with clear speech and history of headache, denies nausea. Her ability to communicate clearly is a positive sign, but the headache history requires further investigation. She denies any visual or auditory hallucinations. This denial helps narrow down potential neurological or psychiatric conditions. Tearing and an itchy, burning sensation in both eyes. These symptoms suggest possible ocular or allergic issues. Headaches have become more debilitating recently. This change in severity is concerning and warrants further evaluation. Some neck pain. Neck pain can be associated with various head and neck disorders. The patient states this is not a new problem, but it has worsened in the past week and is affecting her vision. The worsening of symptoms and impact on vision are critical factors to consider. The patient complains that her eyes are dry. Dry eyes can be a symptom of several conditions, including medication side effects. Her visual acuity is 20/50 OU, 20/40 OD, 20/50 OS. These measurements indicate a decrease in visual clarity. The eyelids are erythematous and edematous with yellow crusting around the lashes. These findings suggest a possible infection or inflammatory condition. She denies any suicidal thoughts or ideations. This denial is important for assessing the patient’s mental health status. She is alert and oriented to person, partially oriented to place but is disoriented to time and place. This disorientation is concerning and may indicate a neurological issue. Review of System and Physical Exam findings are negative other than stated. This information helps focus on the primary symptoms and concerns.
PMH: Hypertension, Hyperlipidemia, Osteoporosis. These conditions may influence the patient’s current symptoms and treatment options. Vital Signs: 98.1 120/64 HR-72 20. These vital signs are within normal limits, providing a baseline for the patient’s current health status. Synthroid 100 mcg daily. This medication is used for thyroid management and may have side effects. HCTZ 12.5mg daily. This diuretic can affect electrolyte balance and blood pressure. Multivitamin daily. Multivitamins are generally safe but should be considered in the context of overall health. Aspirin 81 mg po daily, and simvastatin 40mg. These medications are used for cardiovascular health and lipid management. Rating the pain as 5/10. This pain level indicates moderate discomfort that affects daily activities. Typically takes 1 to 2 tabs of OTC Naproxen with ‘some help’. This suggests that the current pain management may be insufficient. “Sleeping it off in a darkened room’ helps alleviate the headache. This coping strategy indicates sensitivity to light, which is common in certain types of headaches.
Diagnostics/Assessments done: 1. CXR—no cardiopulmonary findings. WNL. This result helps rule out certain respiratory or cardiac causes. 2. CT head—diffuse Cerebral Atrophy. This finding may be related to age or other neurological conditions.
Treatments and prevention: The following are some common treatments based on the type of headache a person may have. Understanding the type of headache is crucial for effective treatment. (some thoughts to consider below) Tension: Tension headaches often cause mild to moderate pain. These are the most common type of headaches and can be managed with lifestyle changes. In some instances, over-the-counter (OTC) pain medication or rest will reduce pain. These options are often the first line of treatment. But if the pain is persistent or occurs frequently, a person may need additional treatment options. Chronic tension headaches may require more comprehensive management.
Some prevention tips for tension headaches include: eating regular meals and not skipping any. Regular nutrition can help maintain energy levels and prevent headaches. Managing stress. Stress management techniques can reduce headache frequency. Getting regular rest. Adequate sleep is essential for overall health and headache prevention. Exercising each day for at least 30 minutes. Regular physical activity can improve circulation and reduce stress. Avoiding triggers such as stress or lack of sleep. Identifying and avoiding triggers can help prevent headaches. Learn about home remedies for headaches here. Home remedies can be a useful adjunct to medical treatment.
Cervicogenic: A person who has a cervicogenic headache should see their doctor for treatment. These headaches originate from the neck and require specific interventions. Since the headache is the result of an underlying condition in the neck, treatments focus on the neck. Addressing the root cause is essential for effective relief.
Typical treatments for cervicogenic headaches can vary, but may include: using nerve blocks. Nerve blocks can provide temporary relief from pain. Taking pain medication. Medications can help manage acute pain episodes. Having physical therapy. Physical therapy can improve neck function and reduce pain. Doing regular exercise. Strengthening exercises can prevent future headaches.
Migraine: Similar to tension headaches, treatment for migraines often involves improving the symptoms and preventing future migraines. Migraines can be debilitating and require a comprehensive management plan.
Some standard treatment options include: using medications, such as pain relievers, triptan or ergotamine drugs. These medications target specific migraine pathways. Resting in a dark, quiet room. This can help reduce sensory overload during a migraine. Drinking plenty of fluids. Hydration is important for overall health and can help reduce headache frequency. Applying a cool damp cloth or ice pack on the forehead. This can provide soothing relief during a migraine. Undergoing hormone therapy. Hormonal imbalances can trigger migraines in some individuals. Managing weight. Maintaining a healthy weight can reduce the frequency of migraines. Writing down things that trigger the migraine headaches and try to avoid them. Keeping a headache diary can help identify patterns and triggers. Managing stress. Stress reduction techniques can decrease the frequency and severity of migraines.
Basic Metabolic Panel as shown below: TEST RESULT REFERENCE RANGE GLUCOSE 90 65–99. This result is within normal limits, indicating stable blood sugar levels. SODIUM 130 135–146. This low sodium level may need to be addressed. POTASSIUM 3.4 3.5–5.3. This slightly low potassium level should be monitored. CHLORIDE 104 98–110. This result is within normal limits. CARBON DIOXIDE 29 19–30. This result is within normal limits. CALCIUM 9.0 8.6–10.3. This result is within normal limits. BUN 15 7–25. This result is within normal limits. CREATININE 70 0.70–1.25. This result is within normal limits. GLOMERULAR FILTRATION RATE (eGFR) 60 >or=60 mL/min/1.73m2. This result indicates normal kidney function.
