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NR509 Week 3 SOAP Note final - Headache
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NR509 Week 3 SOAP Note final - Headache
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SOAP Note TemplateS: Subjective
Information the patient or patient representative told you
Initials: T.J. Age: 28 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies
170cm 88 kg 139/ 82 16 98.9 99% Medication: Penicillin-rash/hives
87 Food: No known food allergies
Environment: Cat dander, Dust-sneezes, pruritus, wheezing, asthma
flare up
History of Present Illness (HPI)
Chief Complaint (CC) “I got into a little fender bender a week ago and I’ve been getting these CC is a BRIEF statement identifying
headaches” and neck pain why the patient is here - in the
Onset Accident was 1 week ago with symptoms starting 2 days after the accident (5 patient’s own words - for instance
days ago) "headache", NOT "bad headache for 3
Location Headache pain in crown and back of head, pain in back of neck muscles days”. Sometimes a patient has more
than one complaint. For example: If
Duration Headache lasts 1-2 hours, neck pain is intermittent
the patient presents with cough and
Characteristics Headache is dull ache sore throat, identify which is the CC
and which may be an associated
Aggravating Factors Pain upon head or neck movement symptom
Relieving Factors Rest and Tylenol as needed
Treatment Takes two Tylenol as needed, usually once a day, unsure of dosage
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Tylenol regular strength 650 mg (2 tablets) Once a day by mouth as The past 5 days Headaches
needed with or without
food
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Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Diagnosed with Type 2 diabetes at the age of 24, non-compliant with diet and medications.
Immunizations up to date with the exception of the flu shot.
Diagnosed with asthma at the age of 2.5 and was last hospitalized at the age of 16.
Heavy menstrual bleeding with irregular cycles, menarche at age 11.
Denis surgical history, broken bones, or recent hospitalizations.
Was hospitalized for asthma when she was a little girl and has never been intubated for asthma exacerbation.
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Single, unmarried, no children
Works 32 hours a week at Mid-American Copy & Ship as a supervisor
Going to school to obtain a bachelors degree in accounting, two months away from graduating
Enjoys reading books on her e-book reader, going to church activities and watching TV
Denies tabacco use, friends smoke when they go out a couple times a month
Used to use illicit drugs-marijuana, denies currently. Used marijuana “a lot” and “every weekend” for 5-6 years, from ages 15-21 and stopped
because it “wasn’t fun” Last usage was age 20-21
Social alcohol use (2 times per month)
Uses seatbelts consistently/Has working smoke detectors in her home
Lives with her mom and sister
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for
death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if
pertinent.
Mother-HTN, HLD/Father-Type 2 diabetes, HLD, HTN-Died 1 year ago at age 58 in a car accident
Brother-Obese, no other known health problems/Sister-Asthma-well controlled and is overall healthy
Maternal grandmother-Died at age 73 from a stroke 5 y ago-Hx: HTN, HLD/ Maternal grandfather-Died at age 80 from heart attack-Hx: HTN, HLD
Paternal grandmother-Possible HTN and HLD, PT unsure/ Paternal grandfather-Died from colon cancer, unknown medical hx, died years ago
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive
symptom and provide additional details.
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