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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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NR509-Week 3 SOAP Note finalSOAP Note Template
S: 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
170 89 kg 140/ 139/ 16 98.9 F 99% Medication: Penicillin: Hives
cm 81 87 Food: Click or tap here to enter text.
Environment: Cat dander and dust: Sneezing, itchy eyes, runny nose,
triggers asthma symptoms
History of Present Illness (HPI)
Chief Complaint (CC) ‘Headache and neckache” CC is a BRIEF statement identifying
Onset 5 days ago why the patient is here - in the
Location Headache: Crown and back of head patient’s own words - for instance
Neckache: Stiffness on sides of neck "headache", NOT "bad headache for 3
Duration Each episode lasts 1-2 hrs days”. Sometimes a patient has more
than one complaint. For example: If
Characteristics Non-radiating dull headache associated with neck stiffness the patient presents with cough and
Aggravating Factors Head movement sore throat, identify which is the CC
Relieving Factors Tylenol with minimal help and which may be an associated
symptom
Treatment 2 regular strength Tylenol
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
Proventil 90mcg 2 puffs Every 4 hour hours as PRN Asthma
needed
Flovent Pt unaware of dosage Once a day This morning Asthma maintanance
Tylenol 2-325 mg regular Once a day 5 days For headache
strength
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enter text. text. to enter text.
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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.
Occassional headaches when reading for extended periods
Asthma: Dx at age 2.5 yrs old
Diabetes: Dx at 24yrs old
Denies any surgeries
Last hospitalization was at 16 yrs old for asthma exacerbation
Reports all Immunization are current
Declines flu vaccine
Last Tetanus booster: Last year
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
Denies tobacco use
Last used Marijuana 3 years ago
Social alcohol use 6-10 drinks a month
Supervisor at Mid-American Copy & Ship
Bachelor’s Accounting student
Enjoys hanging with friends and going to church
Close with mother and sister (Lives together)
Brother lives elsewhere, father deceased from car accident
Always wear seatbelt when driving.
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, Hyperlipidemia
Father: HTN, Type 2 diabetes, Hyperlipidemia, Died in car accident last year
Sister: Asthma
Maternal Grandmother: HTN, Hyperlipidemia, Died from a stroke
Maternal Grandfather: HTN, Hyperlipidemia, Died from a heart attack
Paternal Grandmother:HTN, Hyperlipidemia,
Paternal Grandfather: Typer 2 diabetes, Died of Colon cancer
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