S.O.A.P. NOTE

Case name:	Shirley Naylor

Subject:_________#1_________________    		 Date:  _____1-15-03_________

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

INSTRUCTION:  Using the outline below, please complete a Problem Oriented Medical Record note for the patient you have just seen.

S. SUBJECTIVE DATA:
Presents the problem from the patient's point of view--how he feels.  It may include the chief complaint, present illness, past history, current medications, diet and appetite, and allergies.  In general this is the information you obtained on "History."

Ms. Naylor presents to the clinic today complaining of a left temporal headache that “crept up on her” 2 days ago.  She was moving boxes and lifting things cleaning her garage 3 days ago, and noticed some soreness in her neck after she completed this.  The next day, and on subsequent days, she noticed this soreness mostly in the morning, and it got progressively better through the day.  However, 2 days ago, she developed the pain in her left temporal area, which she describes as “dull” and somewhat constant.  She has taken Advil for the pain, and has gotten some relief, but not complete relief.  About 2 hours after the temporal headache began, she had one episode of vomiting, and felt somewhat better after the emesis.  At the same time as the onset of the headache, she developed some “floaters and squiggly lines” in her eye, but they have resolved.  She has not noticed light sensitivity with this headache.  This patient has a history of intermittent headaches occurring about once monthly, and these are usually relieved by Advil.  She has no family history of migraine headaches, and no personal history of migraines either.  She has never seen a physician for a headache.

Pertinent medical history includes NKDA, a history of asthma for which she takes albuterol (which controls it well), no hospitalizations or surgeries, and a remote past history of irritable bowel syndrome, which typically flared when she was under stress.  This has not been a problem for several years.  She was treated for depression about 4-5 months ago, taking Celexa for approximately 2 months.  She feels that this was triggered by a personal conflict at work, which resolved itself.  She tapered herself off Celexa and feels that the depression has resolved.  She uses no complementary therapies or vitamins, supplements or other medications.

Review of systems includes a 1-month history of fatigue, with no apparent trigger she can identify.  She says she sleeps well, has not lost weight, and has had no fever, chills, or night sweats.  She denies chest pain, shortness of breath, cough, nausea or vomiting (other than that described above), and has experienced no dizziness, clumsiness, or blurred vision (other than the scotomata described above).  She has noticed that her legs go numb if she sits on the toilet for a prolonged period of time (this has been occurring over the past month).

Her social situation includes what she describes as a good relationship with her husband, her 12-year-old son and her 9-year old daughter.  There is no conflict or violence reported in the home.  Ms. Naylor works as a secretary in a real estate firm, and she states the conflicts there have resolved.  She denies any current stressors.

O.   OBJECTIVE DATA
This is a record of the physical examination and includes the specific objective and reproducible findings gathered by observation of the patient, physical examination, laboratory results, procedures.

Temp:  97.1 F, Pulse 72, Respirations 12, BP 112/58
General:  well-developed, well-nourished Caucasian female in no acute distress.  She is alert, oriented and cooperative.
Neuro:  Focused neurologic exam is performed, including cranial nerves (intact), pupils equal, round, responsive to light and accommodation.  Funduscopic exam reveals no papilledema, no hemorrhages or exudates.  Grips are equal and upper extremity strength is 5/5 and symmetric.
ENT:  Neck is supple with no lymphadenopathy.  There is no palpable tenderness over either temporal artery, and no palpable enlargement of the artery on either side.
Musculoskeletal:  There are no tender areas or trigger points over the upper trapezius upon palpation.

A.   ASSESSMENT
This is a list of the problems identified on history and physical examination, and a short, tentative working diagnosis for each.

1.	Headache:  this appears to be a mixed headache pattern, with a trigger event of cleaning out her garage, which leads me to think it is likely a muscle contraction headache.  However, it has features of a migrainous event, including the vomiting and scotomata.  There is no nuchal rigidity and no temporal artery tenderness to indicate either subarachnoid hemorrhage or temporal arteritis
2.	Fatigue
3.	History of depression
4.	History of asthma

P.  PLAN
This describes your plans for the continued investigation, care and management of each problem.  It may include a plan for collecting further information like blood tests or X-rays; a plan for initial treatment with specific procedures or medications; a plan for educating the patient, referral and/or consultations; and a plan for follow-up.

1.	Headache:  will prescribe Anaprox DS 1 po q 8 hrs for three doses, followed by 1 po q 12 hours thereafter.  Take with food.  Will contact this patient this evening to see if she has experienced relief; if not, or if the symptoms worsen at any time, will consider imaging studies, primarily CT.
2.	Fatigue:  Will ask patient to schedule follow-up visit in one week to review the headache pattern, and consider workup to include T4 and TSH, CBC, and more complete physical exam.  Will need to return to the room to discuss this with the patient today.
3.	Depression – monitor and review signs/symptoms at next visit
4.	Asthma – continue albuterol.  Review tobacco and other substance use patterns (did not ask at this visit) at next office visit.
5.	Preventive medicine – discuss pap smear and other routine health maintenance at next office visit.

ORDERS

Please list your orders for laboratory tests and/or procedures below.