SOAP Note for Frequent Headaches

SOAP Note for Frequent Headaches

Chief Complaint: “I have been having frequents headaches lately”

History Of Present Illness: A 25-year-old Hispanic female presents to your clinic with a headache located on right temporal area, pulsatile.

PMH: Frequent Headaches since i was 15, with menses

Drug Hx: Ibuprofen for Headaches

Subjective: Light makes headache worst Nausea associated with headaches. No vomiting, Headaches improve usually with rest, ibuprofen, and sleep, but it is annoying to have to sleep all-day

Vitals: B/P 108/64; Pulse 86; RR 16; Temp 98.6;

General: 25-year-old female appears well developed and well-nourished, healthy appearing, wearing dark glasses in a dim room

HEENT: no injection, anicteric, PERRLA, EOMs intact, without pain to movement; normal vision

Lungs: CTA AP&L

Cardio: S1S2 without rub or gallop

Abdomin: benign, normoactive bowel sounds x 4;

Rectal:Non contributory

Integument: Intacts without lesion masses or rashes

Neuro: Cranial nerves II to XII intact; sensation intact, DTRs 2+ throughout.
Functional neurological exam is WNL

nstructions:

  1. What other subjective data would you obtain?
  2. What other objective findings would you look for?
  3. What diagnostic exams do you want to order?
  4. Name 3 differential diagnoses based on this patient presenting symptoms?
  5. Give rationales for your each differential diagnosis.
  6. What teachings will you provide?

Requirements:

Should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

Answer preview:

word limit:764