Focused SOAP Note
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date
Focused SOAP Note
Patient Information:
Initials S, Age 68, Sex F
S (subjective)
CC: Intractable nausea and vomiting.
HPI: Sue is a 68-year-old female who comes to the clinic complaining of intractable nausea and vomiting. The patient complained that the condition has worsened for the last five weeks and 11-pound weight loss. She experiences a dull and persistent headache. She has difficulty in concentration and blurred vision. She takes Phenergan 12.5 PO every 8 hours as needed for nausea.
Current Medications:
Xarelto Oral 20 MG 30 Tab(s) take one tab daily (C)
Anticoagulants
Metformin HCl Oral 500 MG 60 Tab(s) take 1 Tab(s) po twice a day
Antidiabetics
Lisinopril Oral 5 MG 90 Tab(s) take one tab po daily
Antihypertensives
Metoprolol Succinate ER Oral 25 MG take 1/2 tab ( 12.5 mg ) po daily
Beta Blockers
Atorvastatin Calcium Oral 40 MG 90 Tab(s) Take one tablet orally every hour sleep (Antihyperlipidemics)
Vitamin C Oral 500 MG 1 Cap(s) orally daily
Vitamins(LS)Multivitamins Oral 1 Cap(s) orally daily
Multivitamins(LS)
Hydrocodone-Acetaminophen Oral 10-325 MG 1 Tab(s) orally every 4-6 hr as needed for pain
Analgesics – Opioid
Furosemide Oral 40 MG 1 Tab(s) Twice Daily
Diuretics
Levetiracetam Oral 500 MG 1 Tab(s) Twice Daily
Anticonvulsants(LS)Gabapentin Oral 600 MG 1 Tab(s) Three Times Daily
Anticonvulsants
Phenergan 12.5 PO every 8 hours as needed for nausea
Allergies: NKDA
PMHx: Diabetes and heart attack.
Soc and Substance Hx: No history of substance abuse and alcoholism.
Fam Hx: Diabetes and heart attack.
Surgical Hx: Negative for history of surgical operation.
Mental Hx: Negative for history of mental illness, suicide ideation, anxiety, and depression.
Violence Hx: Negative for history of violence
Reproductive Hx: Information not available about the reproductive health and number of children.
ROS (review of symptoms):
GENERAL: No fever, fatigue, or unexpected weight loss or gain.
HEENT:
• Eyes: Blurred vision.
• ENT: No discharge, nasal congestion, or sore throat.
SKIN: No skin rashes, itching, or lesions.
CARDIOVASCULAR: Negative for chest pain and discomfort.
RESPIRATORY: No coughing or breathing difficulties.
GASTROINTESTINAL: Positive for nausea and vomiting.
GENITOURINARY: No burning sensation while passing urine. Information is not available about the last menstrual period.
NEUROLOGICAL: No numbness or tingling, problems in bowel control, headache, and dizziness.
MUSCULOSKELETAL: Negative for back or muscle pain.
HEMATOLOGIC: No bleeding.
LYMPHATICS: No enlarged nodes.
PSYCHIATRIC: No suicidal thoughts or stress.
ENDOCRINOLOGIC: No history of sweating, polyuria or polydipsia.
REPRODUCTIVE: No recent pregnancy. She is past child bearing age. She is not sexually active.
ALLERGIES: NKDA
O (objective)
Physical exam:
Vital signs: T 98.7F orally, 122/82, RR 18, P 74 regular, wt 100lbs, ht 4’9, BMI 20.
General: alert and oriented to time and place.
HEENT: Oronasopharynx is clear, no discharge, no nasal congestion, and no sore throat.
Neck: Carotid no bruit.
Chest/lungs: CTA AP&L.
Heart: No palpitations.
ABD: Negative for suprapubic tenderness.
Musculoskeletal: Symmetrical muscle growth and development.
Neuro: CN II-XII and DTR intact.
Skin/lymph: No edema or lesions.
Diagnostic results:
There is no specific diagnostic test to determine migraine. Some of the common tests include MRI and CT scans are essential in ruling out other conditions that might affect present similar symptoms (Wijeratne et al., 2019). MRI examines tumors, stroke, bleeding, and infections.
A review of the medical history, including headaches, location and type of pain, and frequency of headaches, can help practitioners diagnose migraine (Wijeratne et al., 2019).
A (assessment)
Differential diagnoses:
Migraine: Migraine is a neurological disease that presents diverse symptoms. One of the major symptoms is severe throbbing pain on the side of the head. The pain triggers vomiting and nausea (Becker, 2017). People with migraine experience mild vision loss or sensitivity to light. The symptoms interfere with daily activities. Preventive and pain-relieving medication can help alleviate the pain. The causes of migraines include stress, bright lights, and smell (Becker, 2017). Changes or disruption of the brain chemicals can trigger migraines.
Subarachnoid hemorrhage: The condition results from bleeding around the brain. It is a life-threatening condition that can trigger symptoms such as headaches, vomiting, and nausea (Sergeev, 2018). Some of the causes of the condition include aneurysm, AVM, or head injury. It can cause disability or death.
Intracranial mass: Brain tumor is a growth that occurs uncontrollably. It can be cancerous or non-cancerous. One of the common headaches is a headache. Other symptoms include nausea, vomiting, loss of vision, or blurred vision (Sergeev, 2018). Treatment of the condition includes chemotherapy, radiation, or surgery.
P (plan)
The condition will require referral to specialists who will diagnose the condition and provide appropriate medication. The referral provides patients an opportunity to receive quality treatment.
Treatment of the condition will require various lifestyle changes, including sleep hygiene, stress management, diet modification (Minen et al., 2016). Patients should take preventive medications to prevent and relieve pain. One of the best medications to prevent and relieve pain is Triptans 25mg. The drugs are effective in addressing multiple migraine symptoms (Burch, 2019). The patient should begin with one tablet daily for three days. The purpose is to review the side effects and effectiveness of the drugs (Burch, 2019). The patient should come back after three days to determine if the drug should be changed or adjusted.
Patient education about migraines will involve educating the patient about the causes of the condition. It will be important to highlight the lifestyle changes that will prevent the condition from occurring (Burch, 2019). Patient education is essential to change the beliefs about migraines.
The patient should come for follow up visits to assess the level and frequency of symptoms (Minen et al., 2016). During the follow-up visits, the patient will explain their experience after lifestyle changes. The information is essential in developing a reliable treatment plan to suppress the symptoms.
Reflection
I learned that migraines could not be diagnosed without several diagnostic tests. The purpose of the diagnostic tests is to rule out other possible conditions. I learned that elderly patients require a friendly approach to the physical examination. The patients can experience other health conditions that may affect their health significantly. I learned that neurological conditions, such as migraines, require lifestyle changes as the best treatment approaches.
Elderly patients experiencing weight loss require immediate care to stop weight loss. Loss of weight among older adults can undermine the recovery process or trigger additional health conditions. Body weakness can lead to weak immunity that can cause other health conditions.
The cultural background of a patient can undermine their recovery. Patients from poor backgrounds can experience challenges in fighting migraines. For example, foul smell, noises, poverty, and negative beliefs can undermine treatment plans and recovery adherence. Some community beliefs argue that traditional medication is effective for the treatment of migraine. It is important to educate the patient to eliminate negative beliefs.
References
Becker, W. J. (2017). The diagnosis and management of chronic migraine in primary care. Headache: The Journal of Head and Face Pain, 57(9), 1471-1481.
Burch, R. (2019). Migraine and tension-type headache: diagnosis and treatment. Medical Clinics, 103(2), 215-233.
Minen, M. T., Loder, E., Tishler, L., & Silbersweig, D. (2016). Migraine diagnosis and treatment: a knowledge and needs assessment among primary care providers. Cephalalgia, 36(4), 358-370.
Sergeev, A. V. (2018). Migraine’masks’: differential diagnosis of acute headache. Journal, 118(1), 96.
Wijeratne, T., Tang, H. M., Crewther, D., & Crewther, S. (2019). Prevalence of migraine in the elderly: a narrated review. Neuroepidemiology, 52(1-2), 104-110.
