Medical Consultation

04-27 Medical SOAP Note: Acute Severe Headache with Photophobia, Nausea, and Neck Stiffness

Date & Time: 2026-04-27 20:21:06

Patient: [Speaker 2]

Diagnosis:

Diagnosis History:

1. Medical History:

• Hypertension diagnosed ~3 years ago; managed with diet changes and regular monitoring; no antihypertensive medications; reported well-controlled.
• No surgical history.
• No prior hospitalizations.
• No known drug allergies.
• Family history: Mother had migraines in her 20s–30s; father has hypertension; sister healthy; no children.
• Social history: Smokes cigarettes (~0.5 pack/day); denies alcohol use; married; in menopause; recent travel to North Carolina for a family reunion one week prior; exposure to a sick 4-year-old who was taken to the emergency department.

2. Medication History:

• Recent over-the-counter analgesics for current headache: acetaminophen (Tylenol) and ibuprofen (Motrin); no relief.
• No chronic prescription medications.
• No reported medication side effects.
• No known drug allergies.

Subjective:

• Chief complaint: Severe headache for 3 days.
• Onset and course: Gradual onset; once established, constant without fluctuation.
• Location and character: Diffuse, “all over,” with prominent frontal involvement; shooting pain down the neck; neck stiffness.
• Severity: 10/10 pain; “worst headache” patient has experienced.
• Provoking factors: Movement and light (photophobia) worsen pain.
• Relieving factors: None; attempts to remain still; OTC analgesics ineffective.
• Associated symptoms: Nausea; vomited twice, particularly with movement; significant functional impairment (unable to work or perform activities).
• Concerns: Fear of serious intracranial pathology (e.g., brain tumor) due to neighbor’s history.

Objective:

• Physical exam details not provided in the transcript.
• No laboratory or imaging results provided.
• Administrative: Clinic plans to verify insurance coverage during visit.

Primary Diagnosis:

• Assessment: Acute severe headache with photophobia, nausea/vomiting, and neck stiffness following recent travel and sick contact; constant, diffuse pain rated 10/10. Differential includes migraine without aura vs. meningitis (given neck stiffness and photophobia), subarachnoid hemorrhage (“worst headache,” but described as gradual onset rather than thunderclap), and other secondary causes of headache. The absence of focal neurologic deficits in the transcript is noted, but exam not documented.
• Suspected Diagnosis: None at the moment

Plan:

• Prescription: Insert more here
• Next Steps/Examination:
• Perform urgent focused neurologic and meningeal exam (vital signs, nuchal rigidity assessment, cranial nerves, motor/sensory, reflexes, coordination).
• Provide antiemetic therapy (e.g., ondansetron) and analgesia per clinic protocol; consider migraine-specific therapy (e.g., triptan) if primary migraine suspected and no red flags after evaluation.
• Consider emergent neuroimaging (non-contrast head CT) given severity and “worst headache” description; if concern persists for subarachnoid hemorrhage with negative CT, consider lumbar puncture.
• If meningitis is suspected clinically, initiate immediate empiric antibiotics per protocol and obtain lumbar puncture after imaging as appropriate.
• Verify insurance coverage concurrently as planned by office staff.
• Follow-up Treatment Plan:
• Reassess after initial evaluation and testing; adjust management based on findings.
• If migraine is confirmed: develop acute and preventive management plan; counsel on trigger avoidance; provide smoking cessation counseling.
• If an infectious etiology (e.g., meningitis) or hemorrhage is identified: hospital admission and specialty consultation (neurology/infectious disease/neurosurgery) with definitive treatment.
• Schedule a follow-up appointment after acute management to review results and monitor symptom resolution.