Tension Headache SOAP Note

MY patient information below Not a real patient, I need help with citation and references and making sure I follow the rubric. I also need more professional writing for Reflection section.
I need this formatted in SOAP Chart and I will upload the requirements as well.. 9 pages APA paper 8-10 references. less than 15% plagiarized.
I will up load the documents that are required to follow along with the SOAP template for the chart.

Name: J.B. Date: 08/09/20202 Time: 1030
DOB: 1/20/1959 Sex: M
CC: Pt stated “I am here for a wellness checkup”

Mr. J.B. is a pleasant 60-year-old caucasian male that presents to the clinic today for a wellness checkup. He stated he has had intermittent headaches after working all day delivering boxes. Onset started two days ago and gradually worsened in the past two hours. Pain is located in his neck and scalp muscles has a throbbing, tense quality. The patient states that pain worsens after lifting boxes all day. Pain is 4/10 at it worst. Reports after taking OTC medication 3/10. Denies nausea, vomiting, no fever. Alleviating factors include lying down and over the counter Extra Strength Tylenol, drinking water.

Extra Strength Tylenol, 2- 500 mg tablets po BID, Testosterone 0.7 ml IM injection once a week
Allergies: NKDA

Childhood: Chickenpox
Adult: Right Torn Labrum

Hospitalizations/Surgeries: January 22, 2019, Torn Labrum Repair
Vaccinations: up to date
Influenza- 2019 TDAP: 2020

Health Maintenance:
Last colonoscopy- 7/24/2018, negative for polyps
Last prostate exam- 12/15/2019, negative for abnormal findings

Mother- Osteoporosis.
Maternal Grandmother- Dementia
Maternal Grandfather- Heart Disease
Paternal Grandmother- Hyperlipidemia
Paternal Grandfather- Parkinson’s Disease
Currently married for 35 year, has four children. Works for UPS delivering packages.
Tobacco-Denies smoking history ETOH-Denies alcohol history
Elicit drugs-Denies illicit drug history Caffeine: Drinks 4 or more Cokes daily

Denies fever, chills, night sweats, fatigue, weakness, denies weight change

Denies HTN, murmurs, angina, palpitations, Denies dyspnea on exertion, orthopnea, PND, edema
Denies Skin, nail, hair changes, Denies lesions, rash, itching, sores, nodules, denies mole changes
Denies Shortness of breath, wheezing, sputum, cough, hemoptysis, pneumonia, asthma, or bronchitis

Denies trauma, itching, complains of throbbing, tense headaches daily, denies blurry vision, no acute vision changes

Denies appetite change, nausea, vomiting, indigestion, dysphagia, changes in bowel movements, abdominal pain, or blood in his stool

Denies hearing loss, tinnitus, vertigo, discharge, earache, hearing aids
Denies urinary frequency, hesitancy, urgency, polyuria, dysuria, hematuria, nocturia, incontinence, kidney stones or infection
Denies rhinorrhea, stuffiness, itching, allergies, epistaxis, bleeding gums, hoarseness, sore throat, sore lymph nodes
Denies muscle weakness, pain, joint stiffness, decreased ROM instability

Denies pain or lumps
Denies difficulty with concentration, poor balance, disturbance in coordination, numbness, inability to speak, falling down, tingling, brief paralysis, visual disturbance, seizure, weakness, tremors, fainting, changes in sleep habits
Wt: 109.1 kg Temp: 98.1 degrees F. Pulse: 68 bpm
Ht:193.04 cm BP: 118/62 Resp: 20

Physical Exam
General Appearance:
Well groomed, orientated x3, and well nourished, in no acute distress
Intact, scarring on right shoulder, pink, and dry. Normal skin turgor. Without lesions or rashes, no tenting of skin
Head has no abnormalities and is free from lesions with normal hair distribution. Free from infestation. Eyes are symmetrical with moist pink conjunctiva with PERRL/EOM. Ears are in line with lateral canthus, free of lesions. The tympanic membrane is pearly gray and free of exudate. The nose is patent and free of discharge. Symmetrical in appearance. Throat has no exudate or erythema. The tongue protrudes straight, and trachea is midline.

Regular rate and rhythm S1/S2, no S3 or S4. No murmurs, gallops, or rubs.
Lung fields are clear throughout. Normal tactile and vocal fremitus. Lungs expand equally. AP/transverse 1:2. Skin is intact and free of lesions, nodules.

The abdomen is soft, with normal bowel sounds active in all four quadrants. No guarding, rebound tenderness or masses. No hepatomegaly.
Steady gait. 5/5 strength in the bilateral upper and lower extremities with full range of motion
Alert, oriented, mood/affect full range, thought process logical. Goal directed

Cranial nerves 2-12 are intact. Motor and sensory intact. Reflexes within normal limits bilaterally
Lab/Special Test:
Differential Diagnosis:
1. E86.0 Dehydration can cause complications including headache. Shaheen, et al (2018).
2. G44.209 Tension headache: patient states, “head throbbing pain” (Cedars-Sinai Medical Center, 2019).
3. E16.2 Hypoglycemia: low blood glucose can cause headaches (American Diabetes Association, 2019).
4. B34.9 Viral Infection: Severe headache can happen from a viral infection that attacks the brain (National Headache Foundation, 2019).
5. H53.149 Eye strain: Digital eye strain can cause headaches. Can occur with outdated eye prescription or lack of prescription when needed, overuse of electronics, reading or detailed work requiring increased focus. According to Shepard & Wolffsohn (2018).
Diagnosis: Tension Headache (ICD 10-G44.209). According to Schub & Avital (2019) Tension-type headache (TTH) is the most common headache in adults and adolescents, affecting 1.4 billion people worldwide. TTH presents with bilateral pressure, tightening, or non-pulsating pain of mild to moderate. TTH characterized by bilateral pressure, tightening, or non-pulsating pain of mild to moderate intensity that is not worsened by physical excertion and occurs without nausea and vomiting. Tension headaches are not disabling but can cause a decrease in a patients quality of life, particulary if symptoms become chronic in nature.
The most important plan is to rule out urgent causes for the patient’s headaches (Bajwa & Smith, 2019). If his symptoms are not emergent in nature, continue with conservative care. Most patients do not require CT scan of the head or MRI unless there are abnormal findings on the neurological exam or the patient’s clinical picture does not match with one of the clinical findings. With the length of time the he has experienced these headache symptoms, there is a low threshold for obtaining images and placing a referral to neurology.
CBC with differential will be drawn today to evaluate overall health and detect wide range of disorders including anemia, infection. CMP will be drawn today to rule out electrolyte imbalance. Given effectiveness of OTC Extra Strength Tylenol 2- 500 mg tablets po BID. I would also prescribe Motrin 400 mg tablet po q6hr; not to exceed 1200 mg/day unless directed by physician.
J.B. will be instructions on the use of the new medication and side effects. He will also be informed to stay ahead of his headache and to notice the oncoming signs. Education on how to ward off tension headaches will set J.B. up for preventing his tension headaches. Education will be given to drink more water while working, apply heat or ice pack to your head for 5-10 mins several times a day, take hot bath or shower to relax tense muscles, improve posture, try to alleviate eye strain by decreasing use of electronic devises. Educations will be given on reducing caffeine cut cokes to 1 daily. Education on when to go to the emergency room for severe headaches “worst pain ever”, vision loss, new onset of seizures, disequilibrium, These symptoms are considered emergent and need further evaluation. Preventative measures will include relaxation techniques and have her make a daily log to identify triggers (U.S. National Library of Medicine, 2019).
Follow up: 2-4 weeks for evaluation home remedies and medication.

Strengths/Weaknesses with plan for improvement: it was very easy for me to join in the conversation with Mr. J.B. and add my own thoughts on the importance of medication adherence. If I had used motivational interviewing, perhaps I could have done a better head-toe examination by utilizing time management in order to get all the systems covered.
Personal Assumptions Values and Perspective: This patient presented as a well- groomed professional person. He was kind and friendly. I made the assumption that he was educated not only in his profession, but also about his overall health status. Perhaps I should have investigated if this patient had been experiencing undesired side effects with his medication regimen and he was too embarrassed to discuss (Egan, 2019).

Alternate points of view:
I would like to believe when I have my own practice. I will strive to be diligent to follow-up when someone presents with a condition that could be life-threatening if gone untreated. Insurance companies have too much control over individuals’ access to care and one example is requiring prior authorization for a particular treatment or medication. I do not want to be the provider who maybe jaded by all the red tape of the insurance company.

Bajwa, Z. & Smith, J. (2019). Acute treatment of migraine in adults. UpToDate. Retrieved from:
Dains, J., Baumann, L, & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis
in primary care. Elsevier: St. Louis, MS.
“Headaches.” (2019). Anxiety and Depression Association of America. Retrieved from:
“Hypoglycemia.” (2019). American Diabetes Association. Retrieved from:
“Immunoglobulins blood test.” (2018). Medline Plus. Retrieved from:
“Migraine.” (2019). Mayo Clinic. Retrieved from:
“Migraine.” (2019). Medline Plus. Retrieved from: https://medlineplus.gov/migraine.html
“Tension headaches.” (2019). Cedars-Sinai Medical Center. Retrieved from:
Shaheen, N., Alqahtani, A., Assiri, H., Alkhodair, R., & Hussein, M. (2018). Public knowledge of dehydration and fluid intake practices: Variation by participants’ characteristics. BMC Public Health, 18(1), 1-8. doi: 10.1186/s12889-018-6252-5
Sheppard, A., & Wolffsohn, J. (2018). Digital eye strain: Prevalence, measurement and amelioration. BMJ Open Ophthalmology, 2018(3), 1-10. doi: 10.1136/bmjophth-2018- 000146
Schub, T., & Avital, O. (2019). Headaches, tension-type. CINAHL Nursing Guide. Retrieved from http://search.ebscohost.com.arbor.idm.oclc.org/login.aspx?direct=true&db ccm&AN=T700399&site=ehost-live&scope=site\
“Viral infection headaches.” (2019). National Headache Foundation. Retrieved from:

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