Review this week’s Learning Resources, and consider the insights they provide about the case study.

Episodic/Focused SOAP Note

Subjective: The patient is a 20-year-old male who complains of intermittent headaches. The headaches are diffuse all over the head, with the greatest intensity and pressure above the eyes, and they spread through the nose, cheekbones, and jaw.

Objective: Physical examination reveals no abnormalities except for mild tenderness to palpation of the temporal region. Neurological examination shows no abnormal findings. The rest of the physical examination was unremarkable.

Assessment: Based on the patient’s symptoms and the physical examination, it is possible that the patient has a tension-type headache. However, other possible causes of the headache should be considered.

Plan: Further investigation is needed to rule out other possible causes of the headache. The patient should undergo a comprehensive history and physical examination. Based on the history, the patient should be evaluated for any possible triggers of the headache, such as stress or certain foods. Diagnostic tests such as a CT scan, MRI, or a lumbar puncture may also be needed to evaluate for any underlying pathology.

Differential Diagnosis:

1. Tension-type headache: This is a common type of headache that is often described as a band-like pressure or tightness around the head.
2. Migraine headache: This type of headache is characterized by recurrent episodes of moderate to severe headaches that are often accompanied by nausea, vomiting, and sensitivity to light and sound.
3. Sinus headache: A headache that is caused by inflammation or infection of the sinuses.
4. Cluster headache: A rare type of headache that is characterized by severe pain on one side of the head, usually around the eye.
5. Temporal arteritis: This is a condition in which the temporal arteries become inflamed and can cause headaches, scalp tenderness, and jaw pain.

References:

1. The International Classification of Headache Disorders, 3rd edition (beta version). (2013). Cephalalgia, 33(9), 629–808. https://doi.org/10.1177/0333102413485658
2. Mayo Clinic Staff. (2021, January 22). Tension headache. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/tension-headache/symptoms-causes/syc-20353977
3. Mayo Clinic Staff. (2019, June 11). Migraine. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/migraine-headache/symptoms-causes/syc-20360201
4. Mayo Clinic Staff. (2021, June 18). Sinus headache. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/sinus-headache/symptoms-causes/syc-20377580
5. Mayo Clinic Staff. (2021, June 23). Cluster headache. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/cluster-headache/symptoms-causes/syc-20352080
6. Mayo Clinic Staff. (2021, June 22). Temporal arteritis (giant cell arteritis). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/temporal-arteritis/symptoms-causes/syc-20376135