S.O.A.P. NOTE

Case name:	Shirley Naylor

Subject:_________2_________________    		 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."

35 year old white female with history of left temporal headahe with associated nausea of three days duration. Vomiting once. Associated with onset of menstral period. Left temporal headache associated with tenderness to touch, throbbing, no rqadiation. Has had similar headache in the past with mentral periods but not as severe as this. Vision slightly blurred, otherwise no flashing lights, scintialations or aother visiual phenomena. Patient has seen floaters in the past. Feet and legs tingle when on toilet for period of time. During periods becomes bloated, irritable and cries more easily. Not resting well at night last month.
	Taking advil for headaches last two days. History of albuterol use for asthma occasionally , celexa about one years ago for depression, Irritible bowel syndrome 10 years ago, Back of neck sore since weekend after working in gargage
	No family history of headaches, father has asthma, mother rheumatoid arthritis.
	Denies alcohol and drug history, contraceptive use, alternative medicine use
	Married 5 years with two children

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.

HEENT: No nuchal ridgitity, PEARL, Fundoscopic exam shows normal optic disks with no papiledema, hemorraghes or exudates, No cervical lymphadenapathy, Throat moist without imflamation, thyroid normal without nodules. Lungs clear.

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: Secondary to PMS vs temporal arteritis vs atypical migraine
2.	History of depression: R/O possible premenstrual dysphoric disorder vs return of major depression
3.	tingling in legswhen on toliet: probably secondary to pressure on sciatic nerve
4.	Stiff neck: Probable strain when working in gaarge, in absense of nuchal ridgity would doubt due to infectious origin.

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.	finish history.
2.	Complete physical exam with complete neuorlogic exam and examine temple for tenderness
3.	Chem 20, CBC with diff, sed rate, Rheumatoid factor
4.	Consider NMRI
5.	follow up in one week after tests obtained, soone4r if sed rate up

ORDERS

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