A 48-year-old male presents with a two-month history of nighttime headaches that are becoming more frequent. The pain awakens him at night. He has no other somatic complaints and no other significant medical history. Complete chart below.
In SOAP format, discuss what questions you would ask the patient (Review of Systems), what physical exam elements you would include, what further testing you would want to have performed (if any), differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals and other team members needed to complete patient care.
Differential Signs/Symptoms Gold Standard Diagnostics
Gold Standard Treatment
Ex: Temporal arteritis (giant cell arteritis/GC A)
Unilateral pain, temporal area with scalp tenderness, skin over artery is indurated, tender, warm and reddened; amaurosis fugax (temporary blindness).
Medical urgency – refer to ED or Ophthalmolog ist
High dose steroids * Dose and route of administration of glucocorticoids for newly diagnosed GCA varies depending on whether patient presents with or without threatened or established visual loss at diagnosis.
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