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A 20-year-old male complains of experiencing intermittent headaches.

A 20-year-old male complains of experiencing intermittent headaches.A 20-year-old male complains of experiencing intermittent headaches.CASE STUDY 1: HeadachesA 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw. Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide  evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.ORDER A PLAGIARISM-FREE PAPER HERESome Information may need to be make up.S.O.A.P. Note Template CASE ID# ____________________________ Subjective Objective Assessment (diagnosis [primary and differential diagnosis]) Plan (treatment, education, and follow up plan)C hie fC om pla intWhat brought you here today…(eg. headache)Chest painH isto ryo fP res en tIl lne ssChronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph formOnset Mr. Foster complaining of chest pain that initially began a month ago but reoccurred 5 minutes ago. He rates his pain at 6/10. He reports the pain is localized to the sub-sternal region and describes it as “squeezing pressure.” He reports the pain is constant and increasing in severity. He denies radiation but reports some pressure in the left shoulder as well. He reports the pain was accompanied by nausea at the onset. Chest pain is relieved when patient sits down. The patient reports becoming increasingly anxious.Location DurationCharacter Aggravating/associatedfactors Relieving factorsTemporal factors – other things going onSeverityP as tM ed ica lH isto ryAdult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current medicationsHypertension – stage II, hyperlipidemia, no surgical history, flu given during flu season, TDAP 2014 Lopressor 100mg po Q day Lipitor 20mg po at bedtime 10pm Omega 3 fish oil 1200mg po BIDF am il yH isto ryInclude Parents, siblings; grandparents if applicable/known, cause of death,Mother : hypertension, type 2 diabetes, age 80 Father :obesity, hypertension, hyperlipidemia, died of colon cancer at 75 years Sister : type 2 DM, hypertension, age 52 years old Brother : died in MVA at 24 years old Paternal grand mother : died at age 78 of pneumoniaP ers on al/ So cia lH isto ryEducation, marital status, occupation, alcohol/drug use, smoking status, sexual history if relevant, exercise, nutrition, religious preference if knownDenies use of tobacco, denies use of cocaine, heroin, marijuana and any illicit drugs. Uses alcohol 2-3 beer per weekR e vie wo fS y ste msGeneral: No fever, chills and fatigue Hair, Skin, & Nails: No rashHead: No dizziness,LOC, or headache Neck: Eyes: Negative for vision, no use of glasses Ears: Negative for hearing loss, bil ear pain, bulging tympanic membrane, negative for vertigo, negative for tinnitus Nose: Negative for loss of smell, nasal congestion and nasal drainageMouth & Throat: Sore throat, tonsils + 2, and redness Cardiovascular:Respiratory: Breasts:A 20-year-old male complains of experiencing intermittent headaches.Gastrointestinal: Musculoskeletal:Peripheral: Neurological:Psychiatric:This study source was downloaded by 100000830998373 from CourseHero.com on 04-17-2022 16:07:32 GMT -05:00https://www.coursehero.com/file/74051884/SOAP-NoteTemplate-Brian-Foster-chest-paindocx/ A 20-year-old male complains of experiencing intermittent headaches. P hy sic al Ex am ina tio nVital signs: 146/88, 98%, 19, 36.7, 104,General Appearance: Well developed, 58 year old Hispanic man, no respiratory distress, well-nourished and developed, good eye contactHEENT: Head is Norma cephalic, no scalp or sinus tenderness, eye conjunctiva is pink, PERRLA, bilateral ears bulging erythematous tympanic membranes, tonsils is enlarged + 2 and redness noted.Neck: Trachea is midline, thyroid is not palpable, no carotids bruits. Lymph Nodes: No cervical or axillary lymphadenopathyChest: Breast sound clear and equal without adventitious sounds.Cardiac: Regular heart rate 104 bpm, S1/S2 with regular rhythm, no murmurs, rubs or clicks present, chest pain 6/10 6/10Abdomen: No distention, , no tenderness to palpation, bowel sound x 4 quad. Genitourinary: Bowel and bladder continentSkin: Skin is warm and dry Musculoskeletal: Able to move all extremitiesNeurologic: Cranial nerves II- XII grossly intact Psychiatric: AOX4,mood and thoughts appropriate to situation, no evidence of disordered thinkingA s se ss me ntPrimary diagnosis: Coronary artery disease with stable anginaDifferential Diagnosis: GERD, PERICARDITIS, AORTIC ANEURYSM, CHFP lan1. Cardiac enzymes : CBC, BNP, AIC, LIPID PANEL, LFT2. ECHO, STRESS TEST, CAROTID DOPPLER, CARDIAC CONSULT,12 LEAD ECG, XRAY,NITRO FOR CHEST PAIN3. May return to clinic if symptoms worsens or go to the nearest ERThis study source was downloaded by 100000830998373 from CourseHero.com on 04-17-2022 16:07:32 GMT -05:00A 20-year-old male complains of experiencing intermittent headaches.

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