ANSWER
Patient Initials in the SOAP Note: J.D.
Date: [Insert Date]
45 years old
Gender: female
Subjective (S): Chief Complaint (CC): “For the past week, I have been experiencing excruciating headaches.”
Present Illness History (HPI):
Onset: A week ago, symptoms started to appear.
Location: Bilateral frontal and temporal areas are the site of the pain.
The duration of a headache is several hours per day.
Features: 8 out of 10 on the pain scale for throbbing discomfort. linked to light and noise sensitivity, as well as nausea.
Stress and bright lights are aggravating factors.
Although the alleviation is just momentary, factors that help include taking over-the-counter acetaminophen and resting in a dark place.
Time: Every day, but especially in the late afternoon.
Severity: Serious, affecting the capacity to function efficiently.
Past Medical History (PMH): No history of migraines; hypertension is managed with medication.
Medication: OTC acetaminophen as needed, 10 mg of lisinopril per day.
There are no recognised allergies.
Family History (FH): Father has high blood pressure; mother suffers from migraines.
Social History (SH): Works a desk job, is sedentary, occasionally drinks alcohol, and does not smoke.
Review of Systems (ROS): General: Indicates exhaustion but rules out chills or fever.
HEENT: Neck stiffness, headaches, and no changes in vision.
Neurological: Reports sporadic lightheadedness but disputes weakening or numbness.
Objective (O): Overall Appearance: Tired but not in any immediate distress; alert and focused.
Vital Signs: Temperature: 98.6°F, RR: 18 breaths per minute, HR: 84 bpm, and BP: 145/90
HEENT: Palpation of both temples reveals mild pain. Students are round, equal, and light-responsive. There is no nuchal stiffness.
Cardiovascular: No irregularities or murmurs, regular pace and rhythm.
Neurological: No localised impairments were observed, and cranial nerves II–XII were intact. Reflexes and strength within typical bounds.
Musculoskeletal: No range-of-motion restrictions or cervical pain.
Other Systems: No noteworthy results.
Evaluation (A):
Primary Diagnosis: Type of Tension G44.209 Headache
Diagnostic Differential: Aura-free migraine (G43.009)
Headache associated with hypertension (R51.9)
Muscle Tension or Cervical Strain (M79.1)
Plan (P): Intervention:
As needed, prescribe 400 mg of ibuprofen every 6 hours to treat pain.
Give advice on stress-reduction methods including mindfulness and relaxation training.
Diagnostics: To rule out any intracranial abnormalities, order an MRI of the brain.
To assess the management of hypertension, suggest a 24-hour ambulatory blood pressure monitor.
Follow-Up: To determine the frequency of headaches and how well treatment is working, make an appointment for a follow-up in two weeks.
If symptoms increase or show no improvement, consult a neurologist.
Patient Instruction:
Inform the patient about stress and good sleep habits as well as other headache factors.
To enhance general health, promote a balanced diet and frequent exercise.
Signed
[Your Complete Name], [Your Qualifications]
[Name of Your Facility/Institution]
This SOAP note includes the required clinical information and follows the provided template. Tell me if you require any specific information or other changes!
QUESTION
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including client behavior, physical assessment, vital signs, and meds.A =Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.P =Plan: Treatment, diagnostic testing, and follow up
- Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.
- You must use the template provided. Turnitin will recognize the template and not score against it.
- Your submission will be reviewed for plagiarism through Turnitin.