Response

Student # 1 -Provide feedback for Sofia – Migraine with aura SOAP note

CC: “I have had headaches these past couple of weeks.”

HPI: This patient is a 23-year-old Caucasian female that presents to the office with an increased frequency of headaches experienced within the past three months.  She would like advice on how to manage these headaches and if it is something she should be more worried about, as her headaches were never that bad in the past.  She noticed that since she started a new job in December her headaches are worse on the left side of her head, and they usually occur at least once and up to two times a month.  She notices before the onset of the headache she becomes sensitive to light and sometimes sees flashes of light in her vision.  She states she wears glasses and recently had an eye exam, and everything was normal.  She also states that she experiences some nausea before the headache starts getting really bad, and rates the headache pain a 6 to 7 out of ten while it is occurring.  She describes it as throbbing pain, and Ibuprofen helps to manage the pain a little bit.  She also notices the headache onset is in the afternoon after a stressful day and lasts for 4 to 5 hours. She also mentioned her older sister gets pretty bad headaches and thinks she may be experiencing the same thing.ROS:Constitutional: Denies fever, chills, weight loss, fatigue, night sweatsHead: Reports frequent headaches, denies head injuryNeurological: Denies syncope, head trauma, seizures, numbness, concentration difficultiesAllergic/Immunologic: Denies food/seasonal allergies, asthma, and frequent infections.

 Medications: none

Allergies: none

Medical History: none

Surgical History: none

Social History: The patient is a 23-year-old female who recently graduated college, and lives at home with her parents.  She works full time, and reports increased stress in her job due to being new in the position.  She denies smoking, illicit drug use, and occasional alcohol use.  She eats and sleeps well, and is not currently sexually active.  She does not report any other social concerns that are present.

 Physical examination:  remarkable all systems

 Assessment:

This patient is a 23-year-old caucasian female that is a new patient that presents to the office with an increased frequency of headaches experienced within the past three months.  She reports her headache pain is mostly on the left side, light sensitivity before the onset, duration of five hours, and a moderate level of pain experienced.  Pt manages her headaches with Ibuprofen.  This patient is most likely experiencing new-onset migraine with aura, due to the way the headaches are presenting.  Migraine with aura presents with focal neurological symptoms (light sensitivity) prior to the headache pain.  She has experienced at least 2 episodes with aura symptoms and then proceeded to full onset headache, which is characteristic of migraine with aura (Adkins et al., 2021). She also has a family history of migraines and increased stress levels which also support a migraine diagnosis.

.Primary Diagnosis: Migraine with aura.

 Differentials:

1.    Common headache: shorter duration of course than migraine, usually relieved with mild analgesics such as Tylenol, no aura present, and pain is less severe

2.    Sinusitis: sinus pressure and congestion, sinus tenderness, nasal congestion

3.    Migraine without aura: no aura present, associated with primary migraine symptoms, can last from 4 up to 72 hours (Cash et al., 2021).

Plan:

This patient will be treated for migraine with aura based on her symptomatology.  The patient will be prescribed Imitrex 50 mg every 2 hrs as long as symptoms persist and instructed to refrain from exceeding the maximum dose which is 200 mg in a 24 hr period.  Other nonpharmacological interventions recommended include the promotion of normal and routine sleeping habits, eating balanced nutritious meals, limiting caffeine and tobacco use, increased hydration, application of cold compresses to areas where the head is hurting, relaxation and mediation techniques, and cognitive behavioral therapy.  In addition to pharmacological and nonpharmacological modalities, the patient will be instructed to keep a migraine journal to assist with the identification of migraine onset and potential environmental or food triggers, which will assist with the prevention of future migraines (Adkins et al., 2021).

Student # 2 - Martha Johnson discussion 7 – Bells Palsy SOAP note

Chief complaint: “I noticed my face looks funny on the right side and my tongue feels weird.”

HPI:  25-year-old female presents to urgent care with a complaint of facial asymmetry and decreased movement on the right half of her tongue. The patient denies any aggravating or alleviating factors. Onset of symptoms was 24 hours ago.  Location of symptoms is limited to the head. Duration of symptoms is one day. Patient denies having similar symptoms in the past. Character of symptoms is “less feeling” and “heavy”. Timing of symptoms is congruent with the third trimester of a current pregnancy.  Severity is described as “not that noticeable, but seems to be progressing a little bit.”Recent hospitalizations? None.Pertinent past medical history. Patient is currently 38 weeks pregnant with her first child.  Patient denies any previous pregnancy.  Patient denies past infection with herpes simplex virus and denies any current symptoms of herpes simplex.  Patient is up to date with all recommended vaccinations.  Patient denies any chronic medical conditions.  Patient has received recommended prenatal care during this pregnancy.Surgical history: None.Family history: Parents are living.  Mother in stable health. Father has controlled type 2 diabetes.  Maternal grandparents are living.  Grandfather with hyperlipidemia and chronic hypertension.  Grandmother is in stable health.Social history: never tobacco, drug, or alcohol use. Patient reports adequate social support.  She lives with her husband, and they are both employed.  Patient works as an office manager in a medical office.Allergies: No known drug allergies.Medications:  Over the counter (OTC) daily prenatal vitamin. No current prescription or OTC medication use.ROS:Neuro: Negative for headaches and dizziness, positive for “weakness” of the right face and right portion of the tongue.Mental health: Patient denies symptoms of depression, anxiety, and suicidal thoughts.

HEENT:  Patient reports drooping of right eyelid, excessive tearing of right eye, and uneven smile.  Patient denied impaired vision.  Patient denies impaired hearing.  Patient denies any recent trauma.

The physical examVital signs:  Temperature: 98.8 oral, O2%: 99% on room air, Blood pressure: 112/72, Respirations: 16 breaths per minute, Heart Rate: 88Focused physical exam: pertinent positives:General: Patient appears well nourished and without distress. Gravida abdomen appears consistent with report of 38 weeks gestation.HEENT:  Head: Weakness of the facial muscles on the right side of the head are observed when the patient is asked to smile, raise her eyebrows, squint her eyes, and pucker her lips.  The patient is able to perform these movements, but the right side of her face is observed to be weaker than the left side.Eyes: Slight drooping of the right eyelid is observed when the patient is asked to smile.  Tearing of the right eye is observed.  Pupils are equal, round, reactive to light, with accommodation.Ears: no abnormal findings.Throat: no abnormal findings.Lungs: clear bilateral lung sounds, no increased respiratory effort.  Respiratory rate and rhythm are normal.Cardiac: no murmur detected; S1, S2 present.Abdomen: Gravida abdomen consistent with 38-week pregnancy.Neuro: alert and oriented x 4. Follows commands.  Sensation was tested on the face.  Sensation is present on both right and left sides of the face.  Weakness of the right facial muscles is observed when the patient smiles, raises her eyebrows, puckers her lips, and squints her eyes.  Patient can fully close her right eye.  No weakness was observed with strength testing of upper and lower extremities.Skin: No evidence of rash or lesions.Psych: normal affect observed.Diagnostics: Order ELISA lab for B. burgdorferi.

Differentials:

1.Lyme disease was ruled out with ELISA (Ronthal & Greenstein, 2022).

2. Herpes zoster was ruled out due to lack of physical exam findings to support the diagnosis (Ronthal & Greenstein, 2022).

3. Otitis media was ruled out with normal physical exam findings of both auditory canals and tympanic membranes (Ronthal & Greenstein, 2022).

Assessment: A 25-year-old female presents to urgent care with a complaint of facial asymmetry and decreased movement on the right half of her tongue. The patient denies any aggravating or alleviating factors. Onset of symptoms was 24 hours ago.  Location of symptoms is limited to the head. Duration of symptoms is one day. Patient denies having similar symptoms in the past. Character of symptoms is “less feeling” and “heavy”. Timing of symptoms is congruent with the third trimester of a current pregnancy.  Severity is described as “not that noticeable but seems to be progressing a little bit.” Patient reports drooping of right eyelid, excessive tearing of right eye, and uneven smile.  Patient denied impaired vision.  Patient denies impaired hearing.  Patient denied impaired speech or swallowing. Patient denies any recent trauma.  Physical exam findings include: Sensation is present on both right and left sides of the face.  Weakness of the right facial muscles is observed when the patient smiles, raises her eyebrows, puckers her lips, and squints her eyes.  Patient can fully close her right eye.  No weakness was observed with strength testing of upper and lower extremities.Diagnosis: Bell’s Palsy.  Bell’s Palsy is a condition where unilateral facial paralysis occurs suddenly due to inflammation of facial nerves (Zhang et al., 2020). While the exact etiology of this condition is unknown, possible causes are being studied including: herpes zoster, Lyme disease, and ischemia (Zhang et al., 2020).  When assessing a patient for this condition it is important to rule out stroke.Treatment Plan: Prescribe prednisone 60mg oral tablet daily for 7 days. The American Academy of Neurology released evidence-based guidelines on the treatment of Bell’s Palsy which gave a level A recommendation for the use of glucocorticoids in all patients diagnosed with acute onset of Bell’s Palsy (Gronseth & Paduga, 2012; Ronthal & Greenstein, 2021).  OTC artificial tears are recommended to be used every four hours during the day, and OTC nighttime ointment preparation of artificial tears is recommended each night until normal movement and strength of the right eye muscles is regained (Ronthal & Greenstein, 2021).Follow up: Bell’s Palsy is a self-limiting condition that causes weakness of the facial muscles (Ronthal & Greenstein, 2021). Most patient’s regain normal muscle function in 3 to 6 months (Ronthal & Greenstein, 2021). Over 80% of patients who receive steroid treatment will achieve complete recovery. 

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