Soap Note


PATIENT PROFILE/PERSONAL DATA
Mathews Ray is a 25-year-old white male married to an Asian lady with one daughter. The patient is a graduate of Arizona University with a bachelor's degree in pure mathematics and applied statistics. He presents in health care with complaints of "continuous headache for the past two weeks."
Complain List:
Headache inception: 2/6/2019
The problem has never been experienced in his life. Therefore, this is the first time he feels so. In addition to that, the patient has no notable inactive problems.

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SUBJECTIVE
The chief reason for visiting the clinic: Ray is a 25 years old white male married man who presents to clinic complaining “I have experienced a disorder in my body whereby I’ve had a prolonged headache in the past two weeks with no signs of healing.” DISCREPANCY DIAGNOSIS
1. Headache associated with tension and stress (ICD-4 code 301.00): Precisely prolonged headache- Mathews Ray is in a graduate, and married to an Asian lady with one child who might be the cause of tension for provision of basic needs. Maybe Mathews is still unemployed, and he spends much of his time thinking about how he will get employed. Either, he is employed, and the career is very tiresome leading to stress to achieve, triggering a tension headache, the most common type of headache known (Jensen, 2015)
2. Brain tumor might be developing in Mathew's head. Mathews complains of experiencing the problem for the past two weeks, under careful examination and pathology, he might have a brain tumor. Most patients who have been diagnosed with a brain tumor have histories of prolonged headache before seeking medical attention (Cabria & Gondra, 2017)
3. Mathews might be suffering from Meningitis. Since he is married to an Asian lady and might be working, there is a probability that he was exposed to viral diseases which caused him Meningitis. However, the possibility of being infected with meningitis is low since the illness is more acute within two weeks of headache. There is no assumption to be made without prior diagnosis. The patient needs to be diagnosed for more information to be obtained regarding his condition.
HPI.
A 25-year-old married man with the lamentation of nonstop headache for the last to weeks. Mathews describes the headache to be humiliating and ponding all the time. The headache causes an increase in blood pressure straining veins in the head. The pounding of the headache can be described on a scale range of 4 to 9, with nine being the worst condition. For the two weeks, the headache has not shown any signs of healing; neither does it has increased beyond the scale of 10. According to the information given by Mathews, he has never been admitted to any hospital regarding the problem or feeling the same. Whenever blood veins expand, they cause tension in the head, causing pain from the back of the head to the forehead. The pain is usually accompanied by laziness and a feeling of dizziness without sensitivity to noise, unclear vision, and photophobia. Mathews has taken painkillers and Ibuprofen whenever the condition was worse and noted some relief. He has been given prescriptions by another physician but has not gotten better. Most of the time, he is in pain and cannot remember all the prescriptions described to him.
Pertinent positive/negatives
1. Stress/tension headache. The advantage part of it is that the headache is consensual, and he has been under stress. The advantage side is that the headache is not banded like, and this disqualifies the compliment from diagnosis.
2. Head tumor. The headache is not severe with only dizziness being the worst part that is positive, whereas the negative arises from no signs and changes in the sight and therefore the low possibility of diagnosis.
3. Meningitis. This has no defined positives but has negatives that exclude the diagnosis. The negativity of it is that there is no fever.
OBJECTIVES
Notable signs: Temperature 96.4 verbally, pulse rate 78, Resp 22, Weight 182lbs, Height 69 inches.
Body examination
Cooperating, inquisitive, bright, patient, and eager to know anything regarding his health. There is no drainage in the outer ears, no pale eyes, hearing is clear as he can hear anything without straining, clear ear canals with no signs of damage
DDX
1. Tension/stress headache. Applicable positives and negatives as the ones mentioned in the upper part. Probably the career might not be the cause of the problem since Mathews denied difficulties in his carrier because he is not employed. There might not be tension or stress to get employed since he admits that he is more focused on his businesses than employment.
2. Brain tumor. The positive and negatives can be applied as the above mentioned. Intracranial pressure does not show any sign in the body. He admitted that headache kicked off after MVP and brain tumor is not likely to be the cause.
3. Meningitis. There are no signs of meningitis from a physical examination made above. There is no photophobia and therefore, no chances of diagnosis.
ASSESMENT PLAN
Based on the above examination and information, post-traumatic headache is the most likely diagnosis as per the code for the general headache (ICD-4 code 301.00): The patient will be coded as mentioned above until more information is obtained about his condition. Further examination of his brain to evaluate the cause of headache was scheduled due in three days. The examination is vital to his head since brain tumor is life threatening and can easily cause death. The examination will help do away with other causes that might be associated with his headache. Mathews was counseled regarding dealing with stress, avoiding unhealthy lifestyle, and keeping his medical checkups updated. Drugs prescribed to him include Motrin 600mg and encouraged to try it whenever the condition is severe (Karadas & Geppetti, 2017). He will visit the clinic in the next one week to collect results and report if Motrin was useful.
Mathews was verbalized on how to maintain his health about health maintenance of male of his age. More focus will be on immunization against meningitis and checking whether he missed any of the vaccinations in his stage, especially polio. If he is more interested in personal business, he needs to go for Hepatitis B since he will come in contact with many people. Use of things to make him tight, such as helmets and seat belts need to be verbalized to keep his life safe. Encouragement to include caloric in his diet and avoiding fats will be crucial. The food should contain more of fruits, vegetables, and enough water. Since business affairs are more tedious, he will be encouraged to set time for rest and recreation to refresh his mind.

References


1. Cabria, I., and Gondra, I. (2017). MRI segmentation fusion for brain tumor detection. Information Fusion, 36, 1-9. doi:10.1016/j.inffus.2016.10.003
2. Jensen, R. (2015). Optimizing headache care for the individual patient. Headache care, research, and education worldwide, 74-82. doi:10.1093/med/9780199584680.003.011
3. Karadas, O., and Geppetti, P. (2017). Pharmacological Treatment of Headache and Comorbidities. Headache and Comorbidities in Childhood and Adolescence, 209-222. doi:10.1007/978-3-319-54726-8_20
4. Robbins, L. D., (20144). Introduction to Tension Headache and Tension Headache Abortive Medication. Management of Headache and Headache Medications, 79-90. doi:10.1007/978-1-4684-0195-0_6

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