SOAP Note: Assessing Neurological Symptoms

Episodic/Focused SOAP Note: Assessing Neurological Symptoms

Patient Information: D.A., 20-year-old Caucasian male (Case study 1: Headache)

SUBJECTIVE:

CC: Headache

HPI:

D.A. is a 20-year-old Caucasian male who came to complain about recurrent headaches, which began 5 days ago. The pain diffuses across the brain and radiates to the nose, cheekbones, and jaw with the highest severity and pressure over the eyes. Headache lasts a few hours and is sporadic. His headache is defined as throbbing pain by the patient. When he coughs and leans over, the pain gets worse. The patient experiences loud, watery nasal flushing as well. The patient has limited rest with the Tylenol 500 mg counter medication he began yesterday. At presentation, the pain level is 7/10. This form of headache has not been documented in the past by patients.

Medications:

Tylenol 500 mg PO taken after every 4 hours as required for controlling headache

Allergies: NKDA

Past Medical History:

No previous hospitalizations

Immunization:

Up to date

Social History:

D.A. is a student taking a degree in nursing.

No history of alcohol.

No history of smoking or using drugs.

Works out in the gym and running

Fond of grilled chicken

He irregularly eats fast food

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Family History:

Maternal Grandfather: Hypertension, age 79

Paternal Grandmother: Hypertension, died of a heart attack at age 80

Paternal Grandfather: Died of Lung cancer at age 68

Sisters age 16 and 12, with no illnesses.

Mother, no illnesses, age 47

Father, Hypertension and Type 2 Diabetes, age 49

Maternal Grandmother: Hypertension, Osteoporosis, age 79

ROS

General:

Denies fever, fatigue, chills, night sweats, or weakness. Denies any recent weight loss

or gain.

Head:

Reports severe headache radiating above the eyes, nose, cheekbones, and jaw. Denies

dizziness, or lightheadedness.

Eyes:

Reports global headache that radiates above the eyes. Denies visual loss, blurred vision,

double vision, eye redness, discharge, or soreness. Wears eyeglasses for reading. The last eye exam

was a year ago. Denies history of glaucoma, photophobia, excessive tearing, or floaters.

Ears:

Denies ear pain, hearing problems, discharges, or changes to hearing.

Nose:

Reports headache that radiates to the nose. Denies nose bleed and nasal polyps. Reports sinus

pressure. Reports a recent history of upper respiratory infection with a runny nose.

Mouth/Throat:

Reports headache radiating to his cheekbones and jaw. Denies chewing or

swallowing difficulties. Denies sore throat. Denies dental or gum problems. Last dental exam 6

months ago.

Neck:

Denies a history of neck problems or injuries. Denies lymph node problems or the presence of

swollen glands. Denies neck stiffness or neck pain.

Respiratory:

Denies shortness of breath or dyspnea on exertion. The patient reports mild non-

productive cough denies hemoptysis. Reports being recently sick with an upper respiratory

infection.

Cardiovascular:

Denies chest pain, pressure, or discomfort. Denies palpitations or peripheral

edema.

Neurological:

Reports headache radiating to eyes, nose, cheekbones, and jaw. Denies weakness,

numbness, or tingling sensation. Denies seizures or syncopal episodes. Denies changes to bowel

or bladder control. Denies problems with balance or coordination. No changes in memory or

thinking pattern. No twitches or abnormal movements. Denies falls or recent trauma.

Musculoskeletal:

Denies myalgia or arthralgia. Denies any recent fracture or muscle injury.

OBJECTIVE:

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Physical Exam:

GENERAL:

Awake, alert, and oriented. Their speech is clear, and answer appropriately. He appears

well-groomed and well-nourished. The patient appears uncomfortable and in pain, with occasional

facial grimacing.

VITAL SIGNS:

BP: 115/63 mmHg, Pulse: 69 and regular, Respirations: 16 and unlabored

Temp: 98.5F. Height: 5’ 6”. Weight 154 lbs. BMI: 24.9.

HEENT:

Head:

Normocephalic and atraumatic. Intact facial sensation.

Eyes:

20/20 visual acuity with glasses. Pupils equal, round, and reactive to light and

accommodation. No AV nicking or exudate was seen on the fundoscopic exam. An ophthalmic exam

reveals a mildly hyperemic disc. EOM is intact. Eyebrows are symmetrical with mild periorbital

edema. Periorbital area and maxillary sinuses tender to touch.

Ears:

Symmetrical. External auditory canal patent, no swelling noted. No abnormal discharges.

Tympanic membranes intact, pearly grey, without erythema or effusion. Passed whisper

test.

Nose:

Symmetrical, no deviation, no flaring noted. No nasal polyps were noted. Clear, watery

discharge was noted from bilateral nostrils. Decreased sense of smell noted. Nasal turbinate is mildly

swollen.

Throat:

Oropharynx with no erythema or exudates noted. Gag reflex intact.

NECK: Supple, full range of motion. Carotid arteries no bruits, no jugular vein distention. No

masses were palpated. No tracheal deviation was noted.

RESPIRATORY:

Lung sounds are clear in all lung fields. No adventitious sounds were noted.

CARDIOVASCULAR:

Heart rate, regular rate, and rhythm. S1 and S2 noted. No murmurs,

gallops, or rubs. Abdominal aorta, no bruits noted. Distal pulses are symmetrical bilaterally, 3+.

No peripheral edema was noted.

NEUROLOGICAL:

CN II – XII is grossly intact. No gait or balance disturbances. Pain sensation

intact to bilateral arms and legs. Deep tendon reflexes to bilateral upper and lower extremities

MUSCULOSKELETAL:

Fully weight-bearing. Upper extremities, spine, hips, and lower extremities with full range of motion. Muscle strength 5/5 in the neck, upper extremities, hips, and lower extremities. No joint effusions, clubbing, cyanosis, or edema were noted.

LYMPHATICS:

No enlarged lymph nodes were palpated.

Diagnostic Tests:

Complete Blood Count with Differential (CBC):

CBC is typically obtained to rule out any headache-causing blood disorders and infectious diseases, such as meningitis or abcession of the brain (Dains, Baumann, and Scheibel 2019). Infection can be associated with pain that is constantly and slowly deteriorating (Earwood et al., 2018). WBC is a typical inflammatory marker. Peripheral edema, pain, and sinus pressure, which may be signs of infection, especially sinusitis, have been observed in the patient.

Erythrocyte Sedimentation Rate (ESR):

An elevated level of ESR implies inflammation but is not unique to any diagnosis of the disease. ESR is a clinical examination obtained while suspected temporal arteritis (Dains, et al., 2019). ESR is also associated with pus in the sinus cavities substantially and autonomously (Ah-See 2015), so an effective laboratory check for sinusitis-related headaches is also possible.

Sinus X-Ray:

Not indicated at this time

Specificities of image studies are used to detect sinus fluids, however, as they are also used in

respiratory tract infections (Ebell, Guilbault & Ermias, 2016). For those who already meet

Clinical diagnosis requirements and X-ray imaging of paranasal sins may be unnecessary. The

American College of Radiology discussed the possibility of comparing the accuracy of the

diagnosis of sinus radiation with clinical criteria (Rosenfeld et al., 2015).

Computed Tomography Scan:

CT scan is a newly created, extreme, and neurologically-related non-invasive initial diagnostic tool for headaches (Dains et al. 2019). It is a new headache, but no focal neurological defects can be identified when evaluated. However, if sinusitis is suspected, the norm of image imaging treatment for sinusitis is considered a high-resolution CT scan with a reformatted, multiplanar image (Rank, Hoxworth & Lay, 2016).

MRI: Not indicated at this time.

MRI in the brain can be performed mainly if a brain abscess is suspected of brain tissue abnormality or tissue pathology (Dains, Baumann & Scheibel 2016). At presentation, there are no signs and symptoms of brain abscess development.

ASSESSMENT:

Differential Diagnosis:

Sinusitis:

Acute rhinosinusitis is temporary, usually for less than four weeks, with swelling of the mucosal lining of the paranasal sinuses (Ah-See, 2015). The location of the sinuses means the development of differential treatments for patients with headaches should consider the paranasal sinuses’ inflammation. It may be challenging to differentiate between rhinosinusitis and primary headache, and patients may experience both disorders. The patient’s signs and symptoms, such as peripheral edema and periorbital and maxillary sinus tenderness, indicate a primary diagnosis of sinusitis.

Tension-Type Headache:

Headache type is a standard type of headache that has an unknown accurate mechanism, but is linked to muscular contraction. This disorder has different symptoms and causes. A pain that lasts several hours or days and is associated with hunger, depression or stress is dull, bilateral, mild, or moderate severity and has no critical related features (Rizzoli and Mullaly, 2018). In the case study, the patient has a modest headache unrelated to depression, starvation, or stress. Furthermore, this form of headache is common in women (Rizzoli & Mullaly 2019).

Migraine Headache:

Migraine headaches are debilitating, neurovascular headaches that sometimes start with alert symptoms of the hypothalamus, brainstem, and cortex (prodromes) and then of the aura of intermittent focus neurological symptoms (Burstein, Noseda, and Borsook, 2015). In various types, Aura will come. Flashes of bright lights, white spots, confused smell, and excitement for the face or limbs are some of the programs and aura a patient may experience in migraine headaches (Viana, Tronvik & Do, 2019). However, the patient’s signs and symptoms seem to be more in keeping with the sinus headache.

Cluster Headache:

Cluster headaches are systemic with a persistent, unilateral, ocular, or periocular onset that is aggravating (Dains et al., 2019). In this case, the patient has global headaches, which are worse over the eyes. For this form of headache, the episode recurrence is divided into periods of days and weeks, along with ipsilateral rhinorrhea, facial sweating, ptosis, and eyelid edema (Dains et al., 2019). The patient in this case, is affected by a headache of rhinorrhea and eyelid edema. Monitoring future headaches and the presence of the usual symptoms mentioned above and their clustering frequency,

Optic Neuritis:

The constellation of symptoms, such as pain in the eye and sub-acute visual failure, is based on optical neuritis (Wilhelm & Schabet, 2015). A slightly increased disc and a blurry disc margin were observed by Dains et al. (2019) when ophthalmoscopic neuritis was examined. Nonetheless, the patient is a student with lenses and tests showing hyperemic discs, so the operator should find optic neuritis as a differential diagnosis. The patient, in this case, does not have the above-mentioned symptoms.

PLANNING:

Not required at this time.

References

Ah-See, IK. (2015). Sinusitis (acute rhinosinusitis).IBritish Medical Journal Clinical Evidence. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4400653/#__ffn_sectitle
Burstein,IR., Noseda,IR., & Borsook,ID. (2015). Migraine: Multiple processes, complex pathophysiology. The Journal of Neuroscience, I35 (17), 6619–6629. Retrieved from https://doi.org/10.1523/JNEUROSCI.0373-15.2015
Dains,IJ.IE., Baumann,IL.IC., & Scheibel,IP. (2019). Advanced health assessment and clinical diagnosis in primary care (5thIed.). St. Louis, MO: Elsevier Mosby.
Ebell, IM. IH., Guilbault, IB., & Ermias, IY. (2016). Diagnosis of acute rhinosinusitis in primary care: A systematic review of test accuracy.IThe British Journal of General Practice,I66(650), e612–e632. Retrieved from https://doi.org/10.3399/bjgp16X686581
Rank, IM.IA., Hoxworth, IJ.IM., & Lay,ID. (2016). Sorting out sinus headache.IThe Journal of Allergy and Clinical Immunology: In Practice,I4(5), 1013-1014. https://doi.org/10.1016/j.jaip.2016.06.021
Rizzoli,IP., & Mullaly,IW.IJ. (2018). Headache.IThe American Journal of Medicine,I131(1), 17- 24. https://doi.org/10.1016/j.amjmed.2017.09.005
Rosenfeld,IR.IM., Piccirillo,IJ.IF., Chanrasekhar,IS.IS., Brook,II., Kumar,IK.IA., Kramper,IM., Corrigan,IM.ID. (2015). Clinical practice guideline: Adult sinusitis.IOtolaryngology, Head and Neck Surgery,I152(2), S1-S39. https://doi.org/10.1177/0194599815572097
Viana,IM., Tronvik,IE.IA., & Do,IT.IP. (2019). Clinical features of visual migraine aura: A systematic review.The Journal of Headache and Pain,I20(64). https://doi.org/10.1186/s10194-019-1008-x
Wilhelm,IH., & Schabet,IM. (2015). The diagnosis and treatment of optic neuritis.IGerman International Journal,I112(37), 616–626. https://doi.org/10.3238/arztebl.2015.0616

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