S.O.A.P. NOTE

Case name:	Shirley Naylor

Subject:_________3_________________    		 Date:  _____1-15-03______

Presenting Situation:  Shirley Naylor is a 35 year old female who presents with a two-day history of headache.
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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."
Shirley Naylor is a 35 year old with a past history significant for asthma who presents to the oupatient clinic complaining of a 2 day old headache.  This is the worst and longest headache she can remember having, although she states she has occasional (once a month) headaches that are less severe and resolve quickly with over the counter meds.  Her present headache began with her menstrual period and is located over her left eye.  She also has some neck pain/occiptal pain that she attributes to doing some heavy lifting over the weekend.  The headache is constant.  It was very severe at onset (midmorning) and was accompanied by visual floaters, nausea and vomiting.  The pain is now less severe, although still present and she still has some nausea, but the vomiting has gone away.  She does not complain of photophobia.  Her headache does not worsen with positional changes.  She does not have any sinus congestion.  She has had no recent eye exam.  She has tried ibuprofen, 400 mg tid, for her headache and it helps a little but has not resolved her pain.  

Ros reveals – feels orthostatically dizzy and tired for 1-2 months, some numbness and tingling of her legs when sitting on toilet.

Family history is negative for chronic diseases.
Pt. Is taking occasional albuterol for asthma.
No smoking, Etoh, recreational or complementary drugs.  Moderate Caffeine.
Married, 2 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.

Tem 97.1, BP 112/58, Pulse 72, Resp12  orthostatics not done
General – no acute distress, pleasant, well nourished.
HEENT normal fundus bilat, cerumen occludes L Tm, R TM normal, EOMI and PERRLA, no ant. Cervical LAN
Neck:  Thyroid without nodules or tenderness.  No JVD
Neuro: Maneuvers to Exam Table without trouble.  Normal quadriceps and ankle reflexes – slightly more pronounced on the left.  Normal sensation to light touch, pin prick and vibration.  

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, combination of migranous and tension type features.  ? eye strain.
2.	Neck Strain secondary to heavy lifting.
3.	Postural dizziness
a.	Anemia
b.	Dehydration
c.	Neurologic deficit such as a polyneruopathy due to a nutritional deficit or progressive neuro disease
4.	Fatigue
a.	As above for dizziness
b.	Stress/ depression
5.	Numbness of legs when sits
a.	Lumbar neuropathy
b.	Sciatic nerve compression secondary to position (most likely)

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.

Rx for headache – continue with ibuprofen, increase dose to 800 mg tid.
		Rx 2 Tylenol #3 for severe pain – do not use at work or while driving
		Keep headache diary if more headaches occur and follow up
		Consider eye exam.
For neuropathy – would check labs, specifically TSH, B12 and Folate.
For dizziness – would rule out anemia with CBC, and check electrolytes/glucose with a BMP plus Ca and Mg levels.

Education – neck stretching exercises for neck strain
		How to keep headache diary – writing down location, duration, onset, triggers, alleviators
		Encourage use of Nsaids as soon as Headaches begin in future
Follow UP – in 1 week to talk about lab results, call office sooner if headache persists or worstens.

ORDERS

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