HPPA 500 E-portfolios First SOAP note

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Headache Case

Complied case information

Mr. J is a 27-year-old man who arrives at his primary care physician’s office complaining of a headache.

He has a long history of mild tension-type headaches managed with acetaminophen. Three days ago, a severe headache suddenly developed while he was weight lifting.

He describes this headache as the “worst headache of his life.” The headache slowly resolved over about 2 hours. He is now feeling completely well. He has been afraid to exercise since this headache.

Mr. J’s past medical history is notable only for mild asthma for which he uses albuterol as needed.

On physical exam, he appears well and not in any distress. His vital signs are temperature, 36.9°C; pulse, 82 bpm; BP, 112/82 mm Hg; RR, 14 breaths per minute. His neck is supple and detailed neurologic exam is also normal.

Mr. J is referred from clinic for a noncontrast head CT. The results are normal.

Given the acute-onset during exercise, the normal neurologic exam, and the lack of symptoms during the intervening 3 days, the patient was thought to have primary exertional headache. A sentinel headache, preceding a SAH, however, was a must not miss alternative. Given this, the patient underwent lumbar puncture that revealed no RBCs and no xanthochromia. He subsequently experienced a similar headache 2 weeks later with exercise. He was then treated with preexercise propranolol with good response.

 

SOAP NOTE

S: A 27-year-old man who complains of having a headache. The patient reports three days ago, a severe headache suddenly developed while he was weight lifting. He describes this headache as the “worst headache of his life.” The headache slowly resolved over about 2 hours. He is now feeling completely well. He has a long history of mild tension-type headaches managed with acetaminophen. The patient’s past medical history is notable only for mild asthma for which he uses albuterol as needed.

O: the patient appears well and not in any distress. neck is supple, detailed neurologic exam is normal.

Vital signs: temperature, 36.9°C; pulse, 82 bpm; BP, 112/82 mm Hg; RR, 14 breaths per minute.

A noncontrast head CT, normal.

 

A: Primary cough headache, primary exertional headache, headache associated with sexual activity, benign thunderclap headache, and intracerebral hemorrhage.

R/O SAH (Subarachnoid hemorrhage)

P: lumbar puncture

treated with preexercise propranolol

 

Summary of SAH differential diagnosis:

  • A middle-aged patient experiences “the worst headache of his life.” Soon after the headache begins, the patient vomits and develops neck pain and stiffness. Patients may also lose consciousness. If the patient is alert at the time of medical assessment, focal neurologic signs and meningismus may be present on the physical exam.
  • SAH is primarily caused by rupture of a saccular aneurysm in or near the circle of Willis.
  • It is generally accepted that anywhere from 10% to 50% of patients will have a warning or sentinel headache in the weeks preceding the SAH. This headache is usually the same sort of abrupt onset (thunderclap) headache as SAH but resolves within 24 hours.
  • Among headaches presenting to the emergency department, SAH accounts for

12% of patients with the “worst headache of my life”

25% of patients with the “worst headache of my life” and neurologic findings

  • Findings that common in patients in whom SAH is ultimately diagnosed: Headache, 90%

In patients presenting with headache, 82.4% report a thunderclap headache, and 99.2% reported the worst headache of their life.

Stiff neck, 75%

Change in mental status, 60%

Stupor or coma, 27%

  • Diagnostic tests:
  • The initial diagnostic test is a noncontrast head CT. The sensitivity of this test varies with the time since the onset of symptoms.
  • CSF examination for RBCs and xanthochromia is the most accurate diagnostic method. Most experts suggest delaying the lumbar puncture for 6–12 hours after the onset of a headache (if clinically safe) in a patient with a suspicious headache and normal CT scan since it takes 12–24 hours for the sensitivity to reach nearly 100%.
  • Importance of correct diagnosis: All patients in whom SAH is suspected should undergo a noncontrast head CT. If the CT is normal, a lumbar puncture should be performed in any patient with more than a minimal pretest probability.
  • About 25% of patients with SAH are initially misdiagnosed.
  • Patients with less severe clinical presentations are most commonly misdiagnosed.
  • Patients who are initially misdiagnosed are only about half as likely to have a good or excellent outcome.
  • Treatment:
  • Prevention of rebleeding: the primary treatment of a SAH is to occlude the culprit aneurysm to prevent rebleeding. For example, deploying platinum coils via arterial catheters within the aneurysm to cause occlusion, and neurosurgical clipping of aneurysms.
  • Prevention of cerebral vasospasm and resulting ischemia: calcium antagonists, primarily nimodipine, decrease the risk of vasospasm.
  • Management of hydrocephalus.