soap note for patient with migraine headache

Please uploaded templete to create a patient with migraine headache. Please use chief complaint ” I have been having a head throbbing pain for two weeks off and on, but now it’s seems to be getting worse”. Make sure that the ROS relates to the finding of what the patient would report for symptoms of a migraine headache. The Physical exam should also relates to finding for the patient with migraine headache. You must include three differentials diagnose, with the correct ICD 10 code and the reason why you pick those based on the patient’s reports, and / findings from the phyical exam. Then used at least two- three evidence based guidelines to formulate a treatment plan, along with patient education. You must also include what labs, or imaging if any is needed. The phyical exam does not have to include all body systems, only one that is pertinent to what relates to finding the diagnose of headaches. Please remember that the uploaded is only an example and can be used as a templete to make the changes needed to fit the disease. And use APA format for references.

Expert Solution Preview

Introduction:

For this assignment, we have been asked to create a patient case with a migraine headache and use evidence-based guidelines and knowledge to develop a treatment plan. The case should include the patient’s chief complaint, a relevant review of symptoms, physical exam findings, three differentials diagnoses with ICD-10 codes, and a treatment plan incorporating patient education and imaging or laboratory tests as appropriate.

Answer:

Chief Complaint:

The patient reports having a head throbbing pain for two weeks off and on, but now it seems to be getting worse.

Review of Systems:

The patient reports symptoms consistent with migraine headaches, including nausea, sensitivity to light and sound, dizziness, and visual disturbances.

Physical Exam:

The physical exam reveals tenderness of the scalp and neck muscles, no focal neurological deficits, and no signs of sinusitis or temporal arteritis.

Differential Diagnoses:

1. Migraine Headache with Aura – ICD-10 code G43.1. This diagnosis is supported by the patient’s chief complaint and review of systems, including visual disturbances.

2. Tension Headache – ICD-10 code G44.209. This diagnosis is supported by the patient’s report of tenderness in scalp and neck muscles.

3. Cluster Headache – ICD-10 code G44.0. This diagnosis is supported by the episodic nature of the patient’s headache and autonomic symptoms such as eye tearing.

Treatment Plan:

The treatment plan for this patient will include the following:

1. Triptans – these medications can be effective in relieving migraine headaches and are recommended in evidence-based guidelines.

2. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) – these medications can be used to relieve pain and inflammation associated with migraine headaches.

3. Patient Education – the patient will be educated on triggers for their migraines, such as stress, alcohol consumption, and sleep deprivation, and taught relaxation techniques to help prevent future migraines.

Lab and Imaging:

Laboratory tests and imaging are not necessary for the diagnosis and management of the patient’s migraine headache. However, if there is a concern for secondary headaches, an MRI or CT scan may be indicated.

References:
1. American Headache Society. The American Headache Society Position Statement On Integrating New Migraine Treatments Into Clinical Practice. 2019.
2. National Institute for Health and Care Excellence. Headaches in over 12s: diagnosis and management. 2019.

Expert Solution Preview

Introduction:

This patient case involves a migraine headache, and the goal is to develop a treatment plan using evidence-based guidelines. The case will include the patient’s chief complaint, review of systems, physical exam findings, three differential diagnoses with corresponding ICD-10 codes, treatment plan, patient education, and recommendations for laboratory tests and imaging as needed.

Answer:

Chief Complaint:

The patient reports experiencing a throbbing head pain off and on for two weeks, which is now worsening.

Review of Systems:

The patient’s symptoms align with migraine headaches, including visual disturbances, sensitivity to light and sound, dizziness, and nausea.

Physical Exam:

The physical exam reveals tenderness of the scalp and neck muscles, no neurological deficits, and no signs of temporal arteritis or sinusitis.

Differential Diagnoses:

1. Migraine Headache with Aura – ICD-10 code G43.1. The patient’s reported symptoms and review of systems support this diagnosis, particularly visual disturbances.

2. Tension Headache – ICD-10 code G44.209. The patient’s report of tender scalp and neck muscles is consistent with this diagnosis.

3. Cluster Headache – ICD-10 code G44.0. The episodic nature of the headache and autonomic symptoms, such as eye tearing, align with this diagnosis.

Treatment Plan:

The following treatment plan will be implemented for this patient:

1. Triptans – These medications can alleviate migraine headaches and are recommended in evidence-based guidelines.

2. Nonsteroidal Anti-inflammatory Drugs (NSAIDs) – These drugs can help relieve pain and inflammation associated with migraine headaches.

3. Patient Education – The patient will be educated on migraine triggers such as stress, alcohol consumption, and sleep deprivation, and taught relaxation techniques to help prevent future migraines.

Lab and Imaging:

Although laboratory tests and imaging are not necessary for diagnosis and management of the patient’s migraines, secondary headaches may require MRI or CT scans.

References:

1. American Headache Society. The American Headache Society Position Statement On Integrating New Migraine Treatments Into Clinical Practice. 2019.

2. National Institute for Health and Care Excellence. Headaches in over 12s: diagnosis and management. 2019.

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