Menstrual migraine, not intractable, with status migrainosus

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wrrc2016

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Description

G43.821 | Menstrual migraine, not intractable, with status migrainosus
Patient Age:12 Years
Patient Sex:F
Patient Enthnicity:White
CLINICAL NOTES (Do not enter patient information that would violate HIPAA confidentiality.):patient seen for menses related migraine not relieved by OTC

HEADSSSVG assessment should be done on all adolescents (starting at about 12 yo), regardless of the visit type (well vs. episodic). Template that must be used is uploaded.

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Pediatric SOAP Note Name: Date: Sex: Age/DOB/Place of Birth: SUBJECTIVE Historian: Present Concerns/CC: Reason given by the patient for seeking medical care “in quotes” Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx) HPI: (must include all components) Medications: (List with reason for med ) PMH: Allergies: Medication Intolerances: Chronic Illnesses/Major traumas: Hospitalizations/Surgeries: Immunizations: Family History (Please identify all immediate family) Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status ROS General Cardiovascular Skin Respiratory Pediatric SOAP Note Eyes Gastrointestinal Ears Genitourinary/Gynecological Nose/Mouth/Throat Musculoskeletal Breast Neurological Heme/Lymph/Endo Psychiatric OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart Weight Temp BP Height Pulse Resp General Appearance and parent‐child interaction Skin HEENT Cardiovascular Respiratory Gastrointestinal Breast Genitourinary Pediatric SOAP Note Musculoskeletal Neurological Psychiatric In-house Lab Tests – document tests (results or pending) Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale For adolescents (HEADSSSVG Assessment) Diagnosis ➢ ➢ ➢ Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials) Document Evidence based Rationale for ROS and each differential with pertinent positives and negatives Primary diagnosis ✓ Is #1 on list of differentials ✓ Evidence for primary diagnosis should be supported in the Subjective and Objective exams. PLAN including education ➢ Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature. ➢ Include EB rationale for all aspects of your treatment plan: ✓ Vaccines administered this visit ✓ Vaccine administration forms given ✓ Medication-amounts and mg/kg for medications ✓ Laboratory tests ordered ✓ Diagnostic tests ordered ✓ Patient education including preventive care and anticipatory guidance ✓ Non-medication treatments ✓ Follow-up appointment with detailed plan of f/u *ALL references must be Evidence Based (EB)
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Explanation & Answer

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Pediatric SOAP Note

Menstrual Migraine
Name:
Institutional Affiliation

Pediatric SOAP Note
Name: H. K.

Date: 22nd OCT 2017

Sex: FEMALE

Age: 12 year
DOB:20th OCT 2005

Place of Birth: Atlanta-Georgia
SUBJECTIVE
Historian: The child and partly the mother
Present Concerns/CC:

“ my daughter has had a severe headache for the past three days; the pain has been so serious that time
she is crying”
“I have been feeling dizzy lately with one episode of vomiting.”
“I have been feeling nausea.”
“Lately I am highly sensitive to light, smell, touch, and sound.”

Child Profile:
H.K. is a 12-year-old white girl, who based on the reports of the mother, has been socially
well before the onset of a persistent migraine. The child states that she can do the majority
of the activities or duties given with less assistance from an adult. The diet of the patient is
comprised of vegetables, fruits, cereals, eggs and foods rich in iron. According to the
mother, the child’s appetite has been good. The mother also states that the child is allergic
to animal fur. H.K. sleeps at 8 PM and wakes up at 6 am on weekdays with normal sleeping
patterns. The child was successfully prompted from 6th grade to 7 grade, and the child says
that she is regularly involved in school activities like sporting. The mother claims that her
daughter has been said to have a good relationship with the teachers as well as fellow
schoolmates. Some of the safety measures put in place by the mother include elimination of
pets and animals at their home due to the allergy of the child, ensuring that H.K wears a

Pediatric SOAP Note
HPI:
The patient claims have been experiencing a severe headache which has taken place for more than 72
hours now. It is stated that the girl started having a slow headache after school with no cases of
vomiting or nausea at the beginning. The patient claims that she does not experience visual difficulties
with some redness on the eyes. A headache has been aggressive to treat through over the counter
medicine as the mother has tried to use some over the counter medications to deal with a headache. The
migraines have brought about depression, anxiety, fatigue, less social and tends to have difficulty to
concentrate
Medications:
Excedrin Migraine 1-2 tablets to relieve the pain

Pediatric SOAP Note
PMH:
Allergies: animal fur
Medication Intolerances: the patient does not
have any medical intolerances reported
Chronic Illnesses/Major traumas: the patient
does have any major traumas, or any chronic
illnesses reported
Hospitalizations/Surgeries: reports indicate that
the patient has not had any prior hospitalizations or
cases of surgery
Immunizations:
the annual flu vaccine
5 shots DTaP vaccine at 6 years old
The meningococcal conjugate vaccine (MCV4) at
11 years
Human papillomavirus (HPV) vaccine at 12 years
(CDC, 2016)
Family History
The patient’s fam...


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