SOAP Note
S: SUBJECTIVE DATA
CC: “I have been having frequent headaches that are becoming more debilitating.”
HPI: The patient is a 19-year-old female with a history of headaches since her teenage years. The headaches have recently become more debilitating, occurring once or twice a month and lasting up to 2 days. The pain begins in the right temple or the back of the right eye and spreads to the entire scalp over a few hours. She describes the pain as sharp and throbbing, gradually worsening and associated with severe nausea. Aggravating factors include loud noises and movement. Over-the-counter medications like naproxen and acetaminophen provide minimal relief. The only effective relief is sleeping in a dark, quiet room.
PMH: No significant past medical history reported.
ALLERGIES: Seasonal allergies and pet dander. No reported drug allergies.
MEDICATIONS: Occasional use of naproxen and acetaminophen for headache relief.
SH: Freshman in college. Sexually active, uses condoms. Denies alcohol, illicit drug, and tobacco use.
FH: Mother suffers from migraines.
HEALTH PROMOTION & MAINTENANCE: Last health visit was over the summer; up to date on health maintenance for her age.
ROS:
Constitutional: Denies fever, chills, night sweats.
Head: Headaches as described in HPI.
Eyes: Denies visual changes other than photophobia during headaches.
ENT: Denies neck stiffness.
Cardiovascular: Denies chest pain, palpitations.
Respiratory: Denies shortness of breath, cough.
Gastrointestinal: Reports nausea with headaches, denies vomiting or abdominal pain.
Neurological: Denies numbness, tingling, weakness.
Psychiatric: Denies changes in mood.
O: OBJECTIVE DATA
VITALS:
Temperature: 98.5°F
BP: 112/70 mmHg
HR: 62 bpm
RR: 17 breaths/min
SpO2: 99% on room air
Height: 68 inches
Weight: 151 lbs
BMI: 23.0 kg/m² (calculated)
PHYSICAL EXAM:
General Appearance: Alert and oriented to self, place, time, and situation. Appears stated age with warm and dry skin.
Head: Normocephalic.
Eyes: PERRL, no tenderness over sinuses.
ENT: TM gray with adequate cone of light bilaterally. Mucous membranes pink and dry.
Neck: No palpable masses, adenopathy, or thyroid enlargement.
Cardiovascular: Regular heart rate and rhythm without murmurs. No edema.
Respiratory: Lungs clear bilaterally, no use of accessory muscles.
Gastrointestinal: Soft, non-tender, non-distended abdomen with normoactive bowel sounds.
Neurological:
Visual acuity 20/20 using Snellen chart.
Face symmetrical with symmetrical smile and puffing out cheeks.
Weber and Rinne tests normal.
Palate and uvula symmetrical at rest and during phonation. Positive gag reflex.
CN XI intact: Shoulders shrug spontaneously and against resistance.
CN XII intact.
Muscle tone normal, strength 5/5 throughout.
Reflexes: Bicep, patellar, and Achilles 2+ bilaterally. Negative Babinski.
Sensation: Able to distinguish light and deep touch.
Coordination: Heel to shin intact, steady gait.
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS:
Migraine without aura (G43.009)
Nausea associated with migraine (R11.0)
VISIT CODES: New patient outpatient visit, level 4 (99204)
P: PLAN
Diagnosis: Migraine without aura (G43.009)
Diagnostics Order:
Complete Blood Count (CBC) to rule out anemia
Thyroid Stimulating Hormone (TSH) to assess thyroid function
Therapeutic:
Prescribe sumatriptan 50 mg oral tablet. Take 1 tablet at onset of migraine, may repeat after 2 hours if needed, not to exceed 200 mg in 24 hours. Dispense #9, 3 refills.
Prescribe naproxen sodium 550 mg. Take 1 tablet at onset of migraine, may repeat after 12 hours if needed. Dispense #18, 2 refills.
Education:
Discuss migraine triggers and the importance of maintaining a headache diary.
Educate on lifestyle modifications: regular sleep schedule, stress management techniques, and avoiding known triggers.
Instruct on proper use of prescribed medications, including potential side effects and when to seek medical attention.
Consultation/Collaboration:
Refer to a neurologist for further evaluation and management of chronic migraines.
Diagnosis: Nausea associated with migraine (R11.0)
Therapeutic:
Prescribe ondansetron 4 mg ODT. Dissolve 1 tablet on tongue every 8 hours as needed for nausea. Dispense #9, 2 refills.
Education:
Advise on non-pharmacological measures for nausea relief, such as ginger tea and small, frequent meals.
PREVENTIVE:
Discuss importance of regular exercise and maintaining a healthy diet.
Recommend daily magnesium supplementation (400-500 mg) as it may help reduce migraine frequency.
Encourage stress-reduction techniques such as mindfulness meditation or yoga.
FOLLOW UP:
Schedule follow-up appointment in 4 weeks to assess effectiveness of treatment plan.
Instruct patient to return sooner if symptoms worsen or if there are any concerning changes.
References:
Eigenbrodt, A. K., Ashina, H., Khan, S., Diener, H. C., Mitsikostas, D. D., Sinclair, A. J., … & Ashina, M. (2021). Diagnosis and management of migraine in ten steps. Nature Reviews Neurology, 17(8), 501-514. https://www.nature.com/articles/s41582-021-00509-5
Mayans, L., & Walling, A. (2018). Acute migraine headache: treatment strategies. American Family Physician, 97(4), 243-251. https://www.aafp.org/pubs/afp/issues/2018/0215/p243.html
Ruschel, M. A. P., Bonfante, J. P., Sharma, S., & Singh, A. (2023). Migraine Headache. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560787/
Tzankova, V., Gantenbein, A. R., Lechner, C., Steiner, T. J., & Olesen, J. (2023). Diagnosis and acute management of migraine. CMAJ, 195(4), E153-E159. https://www.cmaj.ca/content/195/4/E
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NU610 Unit 1 Case Study
A 19-year-old female presents with a complaint of headaches frequently. She reports that she has had them since she was a teenager, but they have become more debilitating recently. The episodes occur once or twice a month and last for up to 2 days. The pain begins in the right temple or the back of the right eye and spreads to the entire scalp over a few hours. She describes the pain as a sharp, throbbing sensation that gradually worsens and is associated with sever nausea. Several factors aggravate the pain including loud noises and movement. She has taken several over the counter medication like naproxen and acetaminophen for the pain but the only thing that makes it better is going to sleep in a dark quiet room. Reports no drug allergies but has seasonal and allergies to pet dander. A thorough history reveals her mother suffers from migraines. Last menses 4 weeks ago, is sexually active uses condoms. Currently a freshman in college. Denies alcohol, illicit drug and tobacco use. Last health visit was over the Summer, up to date on health maintenance for her age. She denies fever, chills, night sweats or neck stiffness. She denies visual changes other than photophobia. She denies chest pain, palpitations, shortness of breath or cough. She denies abdominal pain, has some nausea with the headaches but no vomiting. Denies numbness, tingling, weakness or changes in mood. Vital signs: temperature 98.5, BP 112/70, HR 62, RR 17, 99% RA, Ht. 68 inches, Wt. 151 lbs. Alert and oriented to self, place, time and situation. Appears stated age with skin warm and dry. Normocephalic, PERRL, TM gray with adequate conf of light bilaterally, no tenderness over sinuses. Mucous membranes pink and dry. No palpable masses, adenopathy or thyroid enlargement. Regular heart rate and rhythm without murmurs. No edema. Lungs clear bilaterally, no use of accessory muscles. Soft, non-tender, non-distended abdomen with normoactive bowel sounds. Normal visual acuity using Snellen chart 20/20, face symmetrical with symmetrical smile and puffing out cheeks. Weber and Rinne test performed with normal bone and air conduction. Palate and uvula at rest are free of fasciculations and symmetry noted at test and when pt. says “ah.” Positive gag reflex. Shrug shoulders spontaneously and against resistance, hypoglossal nerve intact. Muscle tone inspected, palpated without atrophy and strength 5/5. Bicep, patellar and Achilles reflexes 2+ bilaterally with negative Babinski. Able to distinguish light and deep touch. Able to complete heel to shin, gait steady.
SOAP Note:
S: SUBJECTIVE DATA
CC: What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI: Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
PMH: This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
ALLERGIES State the offending medication/food and the reactions.
MEDICATIONS Names, dosages, and routes of administration along with indication of use.
SH Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
FH Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known.
HEALTH PROMOTION & MAINTENANCE Required for all SOAP notes: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams.
ROS
(put N/A in sections not completed day of exam) Constitutional
Head
Eyes
Ears, Nose, Mouth, Throat
Neck
Cardiovascular/Peripheral Vascular
Respiratory
Breast
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Neurological
Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Other
O: OBJECTIVE DATA
VITALS: HR: RR: BP: Temp:
SpO2%: Ht: Wt: BMI:
Age: LMP: PAIN:
PHYSICAL EXAM
(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) General Appearance
Head
Eyes
ENT, Mouth
Neck
Cardiovascular/Peripheral Vascular
Respiratory
Breast
Gastrointestinal
Genitourinary Male
• External Exam
• Internal Exam
Genitourinary Female
• External Exam
• Internal Exam
Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Other
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS ICD-10 CODES
PRIORITIZE DIAGNOSIS 1.
2.
3.
VISIT CODES CPT BILLING CODES
DIAGNOSTICS
POC TESTING
TESTS REVIEWED
P: PLAN
ACTIONS 1. Diagnosis:
Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)
Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)
Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.
Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.
2. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
3. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
PREVENTITIVE
(Used for comprehensive exams)
Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver.
FOLLOW UP
