Pediatric SOAP Note
|Name: P. L||Date: 03/09/2018|
|Sex: Male||Age/DOB/Place of Birth: 16 y.o/03/01/2001/Cuba|
|Historian: Mother and patient
Present Concerns/CC: “I’ve been having horrible headaches on and off for the last 2 weeks”
Patient is a high school student with no significant past medical history. He is enrolled in a dual program where he is taking college classes in advance. Described by his mother as an A+ student. He does participate in sports at school being part of the baseball league. Patient goes to school during the day and spends most of his free time studying. He eats a balanced diet including meat, vegetables, and salads. Patient drinks water throughout the day and does not like soda beverages. Denies drinking energetic drinks. He uses seatbelt at all times while in a car.
Otherwise healthy 16 y/o male seen in the office for complaints of daily headache for 2 weeks. Pain is described as dull and pounding and intermittent. Pain is mainly located in the back of the head but at times radiates to the top and to the sides. Patient can’t say if there are specific triggers for the pain because he experiences it at any time. Pain is alleviated by rest and in other instances he has taken Excedrin Extra Strength with little relief. Denies photophobia, blurred vision, or diplopia. Patient admits to some pressure with the studies as he is trying to get a full scholarship for university.
He is not currently taking any medications. Has taken Excedrin Extra Strength 1 tab orally by mouth as needed for headache in the past.
Differential diagnosis –
1. Tension headache (G44.209): Tension headaches are
often described as dull pain on the back of the head or in
forehead. They are also called stress headaches and they
are often the result to high level of stress (Donaldson,
2. Brain tumor (C71.9): While many cases are
asymptomatic, a new onset of headache can warrant
further testing to rule out this diagnosis. According to
Prosad Paul, Perrow & Webster (2014), patients with
brain tumors can have persistent headaches, problems
with coordination, dizziness, fatigue or weakness. This
patient does not present other symptoms; however, this
differential diagnosis is a must no miss and therefore is
included for this patient.
3. Herniated cervical disk (M50.10): Although not very
common, serious cervical pathologies such as herniated
disk can cause headaches (Donaldson, 2016).
Donaldson, S. (2016). Tension Headaches: Psychological Factors. Biofeedback,
44(1), 15-18. doi:10.5298/1081-5937-44.1.06
Prosad Paul, S., Perrow, R., & Webster, M. A. (2014). Brain tumours in children:
reducing time to diagnosis. Emergency Nurse, 22(1), 32-36.