SOAP (Issues) for Nurse Practitioners

Subjective: The patient, a 45-year-old female, presents with complaints of persistent headaches over the past two weeks. She reports that the headaches are throbbing in nature and are accompanied by nausea. She has a history of migraines but notes that these headaches feel different. Recent treatments include over-the-counter pain relief, which has provided minimal relief. The patient also reports that her chronic hypertension remains stable with current medication. Objective: Upon examination, the patient appears in mild distress due to pain. Vital signs are within normal limits, except for a slightly elevated blood pressure of 140/90 mmHg. Neurological examination is unremarkable. Assessment and Plan: - Likely diagnosis: Tension-type headache - Differential diagnosis: Migraine, sinusitis - Investigations planned: MRI of the brain to rule out any structural abnormalities - Treatment planned: Prescribe amitriptyline for headache prophylaxis and recommend lifestyle modifications including stress management techniques Patient Education: - Discussed the importance of maintaining a headache diary to identify potential triggers - Advised on the benefits of regular exercise and adequate hydration - Explained the use of prescribed medication and potential side effects The patient verbalizes understanding and agrees with the plan of care, all questions answered.