SOAP Note Migraines Essay Discussion

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SOAP Note Migraines Essay Discussion

Patient Information: Name: Mrs. K.W. Age: 65 Gender: Female Date: 06/05/2024

Subjective:

Chief Complaint: Migraines

History of Present Illness (HPI): The patient is female, 65 years of age, and today, she is coming to the clinic because of migraines without aura. In the past year, she indicates that she has suffered from headaches of moderate severity at a rate of twice a month at most. The headaches are usually unilateral, of throbbing character, and exacerbated by physical exertion (Robbins, 2021). Before developing headaches, the patient reports no complaints of visual disturbances, sensory changes, or weakness. Nonetheless, she explains that the pain is felt as a throbbing pain in the right temple, and it may persist for several hours. The patient explains that using painkillers from a chemist’s shop helps to some extent, while the headaches affect her ability to work and carry on everyday life. SOAP Note Migraines Essay Discussion

When asked whether the patient has had any recent history of head injury, fever, neck stiffness, altered vision, or focal neurological signs, the patient answers in the negative. She has not felt sick to the stomach or thrown up and has not been bothered by light or sound when she has had headaches. The patient has no family history of migraines, other neurological disorders, or illnesses.

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Medical history includes hypertension with medication the patient is taking to control the condition. She does not smoke; she drinks alcohol in moderation but has no history of illicit drug use. Finally, she describes herself as a customer service representative, leading a very inactive life since most of her time is spent behind a computer. The patient complains of headaches and how they have affected her work performance and other activities. SOAP Note Migraines Essay Discussion

Objective:

Vital Signs:

– Blood Pressure: 130/82 mmHg

– Heart Rate: 72 bpm

– Respiratory Rate: 16 breaths/min

– Temperature: 98.6°F

– Weight: 150 lbs

– Height: 5’6″

General Appearance:

The patient is well-built and well-nourished, with no signs of acute illness. She knows her surroundings, can make good eye contact, and talks in complete sentences. Some of the findings include no signs of distress or abnormal movements.

Neurologic Exam:

Cranial Nerves: II-XII intact

Motor: Strength 5/5 in all extremities

Sensory: Intact to light touch and proprioception

Reflexes: 2+ and symmetric throughout

Coordination: Standard heel-to-shin and finger-to-nose testing

Gait: Typical heel-to-toe and tandem walking

Assessment:

This patient, a 65-year-old woman, has previously been diagnosed with aura-free migraines, which cannot be deemed incurable. The headaches she is experiencing seem to be quite intense and episodic, significantly impacting her life. There were no concerning indications of neurologic abnormalities or subsequent headaches in the clinical history or physical examination. SOAP Note Migraines Essay Discussion

Plan:

  1. Migraine Management:

– Recommend a migraine diary to track headache frequency, triggers, and response to treatment.

– Explain the dietary changes needed, such as reducing stress levels and engaging in physical activities like exercising.

– Administer Botox, 200 units, Intramuscular, once

  1. Hypertension Control:

– Take your antihypertensive therapy and check your blood pressure periodically.

  1. Follow-Up:

Practical tips: Useful hints: In summary, patients should be told to schedule a follow-up visit in four weeks to revise the treatment plan as needed and assess their response to therapy.

  1. Patient Education:

– Supply information about what causes migraines, signs that the migraines are worsening, and when to get professional help (Khan et al., 2021).

The treatment options were explained to the patient, and the importance of compliance with the medications and other necessary changes in his lifestyle were also discussed. She appreciated the effort and was ready to adopt the recommended measures. The patient will follow up when due, and the lady was advised to seek the clinic’s service when she develops complications or other associated symptoms.

 

 

References

Khan, J., Al Asoom, L. I., Al Sunni, A., Rafique, N., Latif, R., Al Saif, S., … & Borgio, J. F. (2021). Genetics, pathophysiology, diagnosis, treatment, management, and migraine prevention. Biomedicine & Pharmacotherapy, 139, 111557. https://www.sciencedirect.com/science/article/pii/S0753332221003425

Noor, N., Angelette, A., Lawson, A., Patel, A., Urits, I., Viswanath, O., … & Kaye, A. D. (2022). A comprehensive review of zavegepant as abortive treatment for migraine. Health Psychology Research, 10(2). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9239361/

Robbins, M. S. (2021). Diagnosis and management of headache: a review. Jama, 325(18), 1874-1885. https://jamanetwork.com/journals/jama/article-abstract/2779823

** Use Migraine SOAP Note**
This assignment aims to incorporate subjective and objective findings to formulate an evidence-based plan using a previously identified disease process. Use a previous discussion from this course where you completed a SOAP Note of a disease process to prepare a narrated PowerPoint. Your presentation must be supported by current evidence, clinical guidelines, clinical investigative skills, expected collaborative inter-professional plan, identify appropriate consultations/referral processes, and incorporate patient-centered plan for teaching and follow-up.

Presentation Guidelines
PowerPoint must be narrated.
Max of 10 slides.
Word documents will not be accepted. SOAP Note Migraines Essay Discussion