SOAP Detailed

Subjective: - The patient, a 45-year-old female, presents with persistent headaches and dizziness for the past two weeks. She reports a history of migraines but notes that these headaches are different in nature, with a throbbing sensation and sensitivity to light. She denies any recent changes in medication or lifestyle. - Past medical history includes hypertension and a cholecystectomy performed five years ago. - Current medications include Lisinopril 10 mg daily and Ibuprofen as needed for pain. - The patient is a non-smoker and consumes alcohol occasionally. - She has no known allergies. The patient describes the headaches as starting in the morning and worsening throughout the day, with a severity of 7/10. She has tried over-the-counter pain relief with minimal effect. She reports feeling fatigued and has experienced some nausea but no vomiting. The patient manages symptoms by resting in a dark room and using cold compresses, which provide some relief. There have been no recent changes in her symptoms or condition. Review of Systems: - General: Reports fatigue and weight loss of 5 pounds over the last month. - Head: Reports headaches and dizziness. - Eyes: No vision changes reported. - Neurological: Reports occasional tingling in the fingers. Objective: - Vital Signs: - Blood Pressure: 130/85 mmHg - Heart Rate: 78 bpm - Respiratory Rate: 16 breaths/min - Temperature: 98.6°F - Oxygen Saturation: 98% on room air - General Appearance: Alert and oriented, appears fatigued. - HEENT: Mild tenderness on palpation of the temples, no sinus tenderness. - Neurological: Cranial nerves II-XII intact, no focal deficits. Assessment: - Headache Assessment: - Likely diagnosis for Headache: Tension-type headache Diagnostic Tests: - Consider MRI of the brain if symptoms persist or worsen. Treatment Plan: - Initiate trial of Amitriptyline 10 mg at bedtime. - Recommend stress management techniques and regular sleep schedule. Follow-Up: - Instruct patient to contact the clinic if symptoms worsen or do not improve within a week, or if test results indicate further evaluation or treatment is needed.