1 soap note

1

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 _______ NU___:_________

Herzing University

Name:_________________________ Typhon Encounter #: _____________________

Comprehensive:____Focused:____

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

SOAP Note _______ NU___:_________

Herzing University

Name:_________________________ Typhon Encounter #: _____________________

Comprehensive:____Focused:____

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

SOAP Note _______ NU___:_________

Herzing University

Name:_________________________ Typhon Encounter #: _____________________

Comprehensive:____Focused:____

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.

SOAP Note _______ NU___:_________

Herzing University

Name:_________________________ Typhon Encounter #: _____________________

Comprehensive:____Focused:____

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