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. O - Patient took Tylenol this morning but reported no relief from the pain. A - The patient's symptoms and history suggest a possible migraine episode, but further evaluation is needed to rule out other potential causes. P - The plan is to further evaluate the patient's symptoms, consider additional diagnostic tests if necessary, and develop a treatment plan.
Differential Diagnosis
- Single Most Likely Diagnosis
- Migraine: The patient's history of migraines, generalized headache, mild nausea, and light sensitivity are all consistent with a migraine episode. The fact that the pain did not subside with Tylenol also suggests a possible migraine, as migraines can be resistant to over-the-counter pain medications.
- Other Likely Diagnoses
- Tension headache: The patient's description of a generalized headache could also be consistent with a tension headache, although the presence of light sensitivity and nausea makes migraine more likely.
- Sinus headache: The patient's symptoms could also be consistent with a sinus headache, although there is no mention of other sinus symptoms such as congestion or facial pressure.
- Do Not Miss Diagnoses
- Subarachnoid hemorrhage: Although unlikely, a subarachnoid hemorrhage is a potentially life-threatening condition that can present with a sudden, severe headache, and must be considered in the differential diagnosis.
- Meningitis: Meningitis is another potentially life-threatening condition that can present with headache, nausea, and light sensitivity, and must be considered in the differential diagnosis.
- Rare Diagnoses
- Cluster headache: Cluster headaches are rare and typically present with severe, unilateral pain, although the patient's symptoms could be consistent with a cluster headache.
- Idiopathic intracranial hypertension: This condition is rare and typically presents with headache, nausea, and vision changes, although the patient's symptoms could be consistent with idiopathic intracranial hypertension.