S.O.A.P. NOTE 

CASE NAME:  SHIRLEY NAYLOR

Presenting Situation:  Shirley Naylor is a 35 year old female who presents with a two-day history of headache.

S. SUBJECTIVE DATA:
History of Present Illness.  The patient presents with a three-day history of  left-sided headache.  She reports seeing "squiggly lines" and one episode of vomiting at the onset of the headache. She has felt nauseous since that time. Other than the initial scotoma, she reports no changes in vision which she describes as "pretty much 20/20." She had started menses on the first day of this headache and reports having cleaned the garage (moving boxes, sweeping, etc.) five days prior to presentation.  She has been taking Advil since the onset of this headache, but with little relief.  On reflection she reports having awakened daily with a headache "in the back of my head" since then. This is in addition to the unilateral headache which has brought her in. Associated symptoms include fatigue, dizziness and lightheadedness worsening over the past month.  The dizziness and lightheadedness are worsened by postural changes such as bending to pick something up.  She reports that her skin "feels itchy" particularly after a hot bath or on exertion  The patient reports that  her “legs and feet fall asleep when she’s on the stool” for about the past month.  She denies nasal congestion, weakness, numbness, chest pain, shortness of breath, weight loss or fever and sleep disturbances.

Past Medical History.   Positive for asthma, controlled with an albuterol inhaler prn, and irritable bowel syndrome, controlled with fiber intake (Metamucil).  The patient experienced an episode of stress-related depression five months ago for which she was treated with Celexa which she discontinued on her own after two months.

Current Medications.   Patient is currently on an albuterol inhaler prn .  She has been taking Advil since the onset of the left temporal headache, but with little relief.
Family History.  Father has a history of asthma.  Mother has a history of rheumatoid arthritis.

Allergies.  No known allergies

Social History.  Patient denies smoking, ETOH use or drug use.  She has been married for five years.  Her husband is supportive.  She has two children from a previous marriage.

O.   OBJECTIVE DATA

	Vital Signs.  
	
Weight:  WNL	BP:  112/58	
Height:  WNL	Pulse:  72	
Temp:  97.1	Resp:  12	
	
	HEENT:  Negative
Neck:  Supple, no lymphadenopathy, thyromegaly or carotid bruits.  No tenderness on palpation of temporal arteries.
CV:  RRR without murmurs, gallops or rubs.  Patient reports a mild feeling of dizziness when asked to bend forward to touch her toes.
	Lungs: Clear to auscultation.
	Abdomen:  No hepatosplenomegaly, masses or tenderness.
Extremities:  No edema, pulses strong and symmetric; Deep tendon reflexes and strength within normal limits.
	Neurological:  Alert and oriented X 3. Neuro exam within normal limits.
	Skin:  Clear; no rashes, dryness or jaundice 

A.  ASSESSMENT

1.	Headache with migrainous and tension components.
2.	Fatigue
3.	Lightheadedness
4.	Hx of Asthma
5.	Hx of IBS
6.	Hx of Depression

P.  PLAN

1.	Symptomatic treatment (NSAID) of headache with close follow-up
2.	CBC, TSH.

Laboratory Follow-up.  Received the next day.  Patient notified by phone.  Headache is improving.

Laboratory Data
CBC and Differential
WBC Count	10.57	
RBC Count 	*6.68	
Hemoglobin	*19.5	
Hematocrit	*58.4	
MCV	87.4	
MCH	29.2	
MCHC	33.4	
RDW	*15.6	
Platelet Count	*540	
MPV	9.8	
ABS Total Neuts	6.48	
ABS Lymphocytes	2.68	
ABS Monocytes	0.53	
ABS Eosinophils	*0.82	
ABS Basophils	0.06	

Peripheral Blood Smear:  

Thyroid Stimulating Hormone (TSH)	1.70	

Arterial Blood Gases
Blood PH	7.44	
PCO2	*32.3 MM HG (L)	
CO2 CNT.	23.3 MMOL/L	
Bicarb	22.3 MMOL/L	
PO2	129 MM HG (H)	
O2 SAT	99.0% (H)	
%O2 Hgb	NP	
Base Excess	0.0	
O2 Admin.	21%	

		

B12 levels	704 pg/ml	

A.   ASSESSMENT
1.	Polycythemia
2.	History Asthma
3.	History Irritable Bowel Syndrome
4.	History Depression

P.  PLAN
1.	Recheck CBC, Peripheral Smear, ABG, B12 binding capacity.
2.	Phone consult urgently with hematologist.
3.	Send to Transfusion Medicine for Phlebotomy, 500cc. Blood replaced with normal saline (As per phone consult with hematologist.)
4.	Refer to hematologist for evaluation and probable bone marrow biopsy.