Report Example: Patient with Long-term Headaches

Patient Profile / Identification Data

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Lady Antebellum is a 24-year college student who is in her final year. She has experienced headaches for three consecutive weeks and is very much concerned about her health. She is about to sit for her exam, and she has been thinking that maybe it's the pressure to read that has been making her body succumb to stress.

Problem Listing

Headache commencement 9/17/02

(No preceding medical setbacks, no motionless challenges).

Clinical Session: SOAP Format

Subjective

CC/Cause of Visit: Antebellum is a 24-year-old white Hispanic married college student who came to the clinic saying that, I've had a headache for three weeks, and it's still there. There are several possible causes of her condition, and they include:

Differential Diagnosis i.e. possible reasons why she may be experiencing headaches.

Migraines

Migraines could be the reason why Lady Antebellum is having recurrent headaches. The recurring throbbing headache that is basically on one side of the brain and is often time followed by disturbed vision and nausea; perhaps this may be the problem (Barnett, Gallimore, Kopacek & Porter, 2014).

Brain Tumor

A brain tumor is characterized by growth inside the head that is restricted by space; the restricted space is what causes the headaches.

Meningitis

Meningitis could be a causative agent to the headaches, but it is very much unlikely that it is the reason why she is experiencing headaches. Normally meningitis kills after three days of serious headaches.

PTSD

Post-Traumatic Stress Disorder may be the reason why Lady is so much stressed. Her oncoming examinations and fear of failure in relation to her past failures may be the reason why she is having recurrent headaches (McNeil & Quentin, 2014).

It is worth mentioning that the symptoms have gotten worse since onset. The quality of pain is sharp, and the lady rates the severity at 7 on a scale of 1 to 10. There are no additional symptoms to the pain that Lady Antebellum is already going through and the patient has not seen another health care service provider for the symptoms she has been experiencing.

Objective

What was ailing lady antebellum is depression; she was reliving past failures; avoiding books in some instances because they sort of reminded her of times when she was not successful in exams. It is worth mentioning that Lady had a problem concentrating in the classroom, remembering coursework details, and arriving at decisions. She had feelings of tiredness every now and then and also had decreased energy. She at times felt as if she had no worth whatsoever. In a nutshell, her approach to life was characterized by pessimism.

Assessment

The medical diagnosis for this particular visit is depression. A condition that is caused by heightened levels of worry and anxiety (Koutoukidis & Stainton, 2016).

Plan

The best course of action to take is for Lady Antebellum to start taking antidepressants which will improve her condition. In addition to that, therapy and counseling sessions will also do her good. Finally, it is recommended that she takes up an exercise plan that will boost her feel-good hormones, and boost serotonin.

ACA Ethical Principles

Ethics apply in this situation in that the condition of the patient will be kept confidential. By no means will the information be in the disposition of another party other than the psychologist involved; whether by word of mouth or by careless storage of records.

Self-Evaluation of Applied Interviewed Tasks

The interview with Lady Antebellum was successful because the solution to her problem was found. She got to receive medication and was taken on a therapy program.

References

Barnett, S. G., Gallimore, C., Kopacek, K. J., & Porter, A. L. (2014). Evaluation of electronic SOAP note grading and feedback. Currents in Pharmacy Teaching and Learning, 6(4), 516-526.

Koutoukidis, G., & Stainton, K. (2016). Essential Enrolled Nursing Skills for Person-Centred Care. Elsevier Health Sciences.

McNeil, D. W., & Quentin, L. L. (2014). Clinical interviews: Empirical overview and procedural recommendations. The Wiley Blackwell Handbook of Social Anxiety Disorder, 269-291.