NUR 600 Assignment 11.2: Writing a SOAP Note
Assessment
Differential Diagnoses
Sinus Headache: Common symptoms of a Sinus headache include facial pain and pressure, nasal and sinus congestion, and headache. The headache is usually pulsating or throbbing and is moderate to severe. It usually occurs in the sinuses, the area of the cheeks above the maxillary sinus, the bridge of the nose above the ethmoid sinus, or the eyes above the frontal sinus (Maurya et al., 2019). Sinus Headache is a presumptive diagnosis based on DP’s symptoms of throbbing, intermittent, diffuse, moderate headaches. Besides, the headache is aggravated by activity. He also has pressure above the eyes, nose, cheekbones, and jaw, where the sinuses are located. Other pertinent positive findings include rhinorrhea, nasal drip, tenderness over sinus areas, palpable sinuses, and a history of chronic sinusitis.
Cluster Headache: It manifests with headache attacks that are usually severe or very severe and strictly unilateral pain occurring in the orbital, supraorbital, or temporal regions (De Corso et al., 2018). It lasts 15 to 180 minutes and can occur once to 8 times a day. This is a differential diagnosis based on the patient’s symptoms of headache, pain in the orbital, supraorbital, or temporal regions, and nasal congestion. However, DP has a diffuse, bilateral headache, ruling out a primary Cluster headache diagnosis.
Episodic Tension-Type Headache (TTH): Episodic TTH is a differential diagnosis based on pertinent positive findings of the diffuse headache of moderate intensity. Pertinent negative findings include a non-pulsating headache and scalp and neck tenderness (García-Azorín et al., 2020). Besides, the patient’s headache is aggravated by activity, which rules out TTH as a possible diagnosis.
Plan
Medication plan: Tylenol 500 mg PRN.
Saline nasal spray to thin mucus.
Phenylephrine nasal decongestant alleviates sinus swelling and drains mucus (Maurya et al., 2019).
Non-pharmacologic: Warm compressions on tender areas of the face.
Health Education: The patient will be educated on regular physical exercises, stretching, massage, balanced meals, and adequate sleep to prevent frequent headaches. Massage helps to relieve tight muscles in the back of the head, neck, and shoulders, alleviating headaches (May, 2018).
Consultation: Otolaryngology consultation if the headache worsens.
References
De Corso, E., Kar, M., Cantone, E., Lucidi, D., Settimi, S., Mele, D., Salvati, A., Muluk, N. B., Paludetti, G., & Cingi, C. (2018). Facial pain: sinus or not? Acta otorhinolaryngologica Italica: organo ufficiale Della Societa italiana di otorinolaringologia e chirurgia cervico-facciale, 38(6), 485–496. https://doi.org/10.14639/0392-100X-1721
García-Azorín, D., Farid-Zahran, M., Gutiérrez-Sánchez, M., González-García, M. N., Guerrero, A. L., & Porta-Etessam, J. (2020). Tension-type headache in the Emergency Department Diagnosis and misdiagnosis: The TEDDi study. Scientific reports, 10(1), 2446. https://doi.org/10.1038/s41598-020-59171-4
Maurya, A., Qureshi, S., Jadia, S., & Maurya, M. (2019). “Sinus Headache”: Diagnosis and Dilemma?? An Analytical and Prospective Study. Indian journal of otolaryngology and head and neck surgery: official publication of the Association of Otolaryngologists of India, 71(3), 367–370. https://doi.org/10.1007/s12070-019-01603-3
May A. (2018). Hints on Diagnosing and Treating Headache. Deutsches Arzteblatt international, 115(17), 299–308. https://doi.org/10.3238/arztebl.2018.0299
