S.O.A.P. NOTE

Case name:	Shirley Naylor

Subject:_________4_________________    		 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."
MS. Naylor is a 35 yo woman who presents complaining of headache for the past 3 days.  Headache is described as beginning after awakening, L temporal throbbing pain, that was associated with nausea and vomiting once of the first day.  Intensity of pain was about 6-7/10 at first; today pain is around 4-5/10.  She denies precipitating factors, but noted that the day prior she had been working and lifting in her garage, and had noted some posterior neck pain and stiffness by the end of the day.  Her menstrual period also started on that same day.  Advil seemed to relieve the pain only minimally.  She denies photophobia, but did describe some visual floaters or possibly scintillating scotoma as the headache progressed.  She has never had a headache like this one before.

Additionally, Ms. Naylor complains of unusual fatigue over the past month.  She complains of a vague dizziness exacerbated by position change. She denies head trauma, fever, chills, head injury, or unusually heavy menses.  She describes herself as normally in good health.  She denies preceding travel, exposures or illnesses.

Her past medical history is significant only for mild intermittent asthma.  She uses Albuterol for that only as needed.  There has been no recent exacerbations of her asthma.  She denies any drug allergies.  Her only medications include prn Albuterol use and the recent Advil use.  She has had no past surgeries, and her only hospitalizations were for her two deliveries.  She does not smoke, drink alcohol or use any illicit drugs.  Her menstrual cycles are regular.  She and her husband use the rhythm method for contraception.  Family medical history is significant for asthma in her dad and rheumatoid arthritis in her mom.

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.

Vital signs were all within normal limits.  Ms. Naylor appeared well nourished, well-groomed, pleasant and in no acute distress.  Heent exam was unremarkable.  Cranial nerve exam showed no deficits.  There was no thyromegaly, LAN orbruits on neck exam.  There was mild posterior cervical stiffness and tenderness on range of motion of her neck exam, otherwise ROM was full. Heart exam and lung exam was wnl’s.  Abdomen was benign.  DTR’s of upper and lower extremities intact.  Babinski’s downgoing bilaterally.  Strength, tone, balance on gross motor and neurologic exam were intact.  Heel and toe gait were normal.  She had full ROM of her back on flexion.  She complained of mild dizziness with bending. 

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-  unilateral, throbbing, severe headache associated with visual aura and nausea seems to fit a possible migraine headache.  DDX includes cluster, tension headaches.  With no focal neurologic symptoms it seems unlikely that she has intracranial tumor or bleed, however, she has had no previous history of headache and did complain of some strange leg paresthesias on using the bathroom.
2.	Fatigue- accompanied by some dizziness.  Cardiovascular exam normal.  Need to rule out anemia or thyroid disorder.  Rule out diabetes.
3.	Neck stiffness and bilateral leg paresthesias- unclear etiology as neurological exam normal.  Rule out neuromuscular disorders (myasthenia gravis, MS, peripheral neuropathy) on follow up exam

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.	Treat with tryptan or narcotic pain medication short term.  Follow neurologic symptoms. Consider imaging if more symptoms.
2.	CBC,CMP UA stool hemoccult.  Consider 

ORDERS

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