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Episodic/Focused SOAP Note: Assessing Neurological Symptoms
Students Name:
Institution:
Course Code:
Instructor’s Name:
Date:
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Episodic/Focused Note
Patient Information: D.A. 20-year-old Caucasian male (Case study 1: Headache)
SUBJECTIVE:
CC: Headache
HPI: D.A. is a 20-year-old Caucasian male who came to complain about recurrent headaches
which began 5 days ago. The pain diffuses across the brain, and radiates to the nose, cheekbones
and jaw with the highest severity and pressure over the eyes. Headache lasts a few hours and is
sporadic. His headache is defined as throbbing pain by the patient. When he coughs and leans
over, the pain gets worse. Patient experiences loud, watery nasal flushing as well. Patient has
limited rest and relaxation with the Tylenol 500 mg counter medication he began yesterday. At
presentation, the pain level is 7/10. This form of headache has not been documented in the past
by patients.
Medications:
Tylenol 500 mg PO taken after every 4 hours as required for controlling headache
Allergies: NKDA
Past Medical History:
No previous hospitalizations
Immunization:
Up to date
Social History:
D.A. is a student taking degree in nursing.
No history of alcohol.
No history of smoking or use drugs.
Works out in the gym and running
Fond of grilled chicken
He irregularly eats fast food
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Family History:
Maternal Grandfather: Hypertension, age 79
Paternal Grandmother: Hypertension, died of heart attack at age 80
Paternal Grandfather: Died of Lung cancer at age 68
