SOAP Note
S - 19-year-old male presents with a headache that has been ongoing for a full day, reports a history of migraines, and describes the pain as generalized across his entire head, accompanied by mild nausea and light sensitivity. He took tramadol this morning without relief. O - Vital signs and physical examination findings are not provided. A - Differential diagnosis for the patient's headache:
- Single Most Likely Diagnosis
- Migraine: Given the patient's history of migraines and symptoms such as generalized headache, mild nausea, and light sensitivity, this is the most likely diagnosis. The fact that tramadol did not provide relief does not rule out migraine, as it may not be effective for everyone.
- Other Likely Diagnoses
- Tension headache: Could be considered given the generalized nature of the headache, though typically tension headaches are less severe and not accompanied by nausea or light sensitivity.
- Medication overuse headache: Since the patient took tramadol without relief, there's a possibility of medication overuse headache, especially if he frequently uses pain medications for his migraines.
- Do Not Miss Diagnoses
- Subarachnoid hemorrhage: Although less likely given the patient's age and lack of sudden onset, it's crucial to consider due to its high mortality rate if missed. Symptoms can sometimes be similar to migraine, especially if the patient has a history of migraines.
- Meningitis: Infection that inflames the meninges, which could present with headache, nausea, and sensitivity to light. Fever and neck stiffness are common but not universal symptoms.
- Intracranial hemorrhage or stroke: Though rare in young individuals, these conditions can present with sudden onset of headache and require immediate medical attention.
- Rare Diagnoses
- Idiopathic intracranial hypertension: Characterized by increased intracranial pressure without a detectable cause, often presenting with headache and sometimes nausea and visual disturbances.
- Temporal arteritis: Uncommon in someone as young as 19, but could be considered if there are other systemic symptoms such as fever, jaw claudication, or visual disturbances. P - Plan would include a thorough neurological examination, possibly imaging studies (like CT or MRI) if a "do not miss" diagnosis is suspected, and consideration of lumbar puncture if meningitis is a concern. Treatment would depend on the final diagnosis but could include specific migraine therapies if migraine is confirmed, and addressing any potential medication overuse.