Problem-focused SOAP Note for a 42-year-old female

Posted: August 7th, 2024

Week 3 Problem-Focused SOAP Note Example

Submit a problem-focused SOAP note for grading. You must use an actual patient from your clinical practicum who presents with one or more chief complaints.

Use the format below for your SOAP note.

Use the current APA format to style your paper and cite your sources. Review the rubric for more information on how your assignment will be graded.

Problem-focused SOAP Note Format

Demographic Data

Age, and gender (must be HIPAA compliant)
Subjective

Chief Complaint (CC): A short statement about why they are there
History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment
Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance
Family Hx: any history of CA, DM, HTN, MI, CVA?
Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
Objective

Vital Signs
Physical findings listed by body systems, not paragraph form- Highlight abnormal findings
Assessment (the diagnosis)

At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each
Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation
Plan

Dx Plan (lab, x-ray)
Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)
Pt. Education, including specific medication teaching points
Referral/Follow-up
Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due (USPSTF guidelines)
Reference

Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.

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Problem-focused SOAP Note

Demographic Data: 42-year-old female

Subjective:

Chief Complaint (CC): “I’ve had a terrible headache for the past three days.”

History of Present Illness (HPI): 42-year-old female presents with a severe headache that began three days ago. The pain is localized to the right temporal region and described as throbbing and intense, rating 8/10 on a pain scale. The headache is constant but worsens with bright lights and loud noises. The patient reports nausea but no vomiting. Over-the-counter ibuprofen provides minimal relief. She denies visual disturbances, fever, or neck stiffness. The patient has a history of occasional tension headaches but states this pain is different and more severe than her usual headaches.

Past Medical History (PMH):

Hypothyroidism, diagnosed 5 years ago, well-controlled on levothyroxine

Seasonal allergies

No prior surgeries

Medications: Levothyroxine 100 mcg daily, loratadine 10 mg daily as needed

Allergies: None known

Immunizations: Up to date on Tdap and influenza vaccines

Family History:

Mother: Type 2 diabetes, hypertension

Father: Myocardial infarction at age 60

No family history of migraines or other neurological conditions

Social History:

Married, two children

Works as an elementary school teacher

Non-smoker, occasional alcohol use (1-2 glasses of wine per week)

Exercises 2-3 times per week (walking, yoga)

Balanced diet, but admits to increased stress and irregular meals in the past week due to end-of-year school activities

Review of Systems (ROS):

General: Denies fever, chills, or unexplained weight changes

HEENT: Reports photophobia, denies vision changes or ear pain

Cardiovascular: Denies chest pain or palpitations

Respiratory: Denies shortness of breath or cough

Gastrointestinal: Reports mild nausea, denies vomiting or changes in bowel habits

Musculoskeletal: Denies joint pain or muscle weakness

Neurological: Denies numbness, tingling, or weakness in extremities

Psychiatric: Reports feeling anxious due to pain and work stress

Objective:

Vital Signs:

Temperature: 37.0°C (98.6°F)

Blood Pressure: 128/82 mmHg

Heart Rate: 76 bpm

Respiratory Rate: 16 breaths/min

O2 Saturation: 99% on room air

Physical Examination:

General: Alert, oriented, in mild distress due to pain

HEENT:

Pupils equal, round, reactive to light

Extraocular movements intact

No conjunctival injection

Tympanic membranes clear bilaterally

Nasal passages patent, no discharge

Oropharynx clear, no erythema

Neck: Supple, no meningeal signs, no carotid bruits

Cardiovascular: Regular rate and rhythm, no murmurs

Respiratory: Clear to auscultation bilaterally

Abdomen: Soft, non-tender, no organomegaly

Musculoskeletal: Full range of motion in neck, no tenderness

Neurological:

Cranial nerves II-XII intact

Strength 5/5 in all extremities

Sensation intact to light touch

Reflexes 2+ and symmetric

No pronator drift

Negative Romberg test

Assessment:

Differential Diagnoses:

Migraine without aura Rationale: Throbbing unilateral headache, photophobia, nausea, and no prior history of migraines. The pain is more severe than the patient’s usual tension headaches. Pertinent positives: Severe pain, photophobia, nausea Pertinent negatives: No visual aura, no family history of migraines

Tension-type headache Rationale: Patient has a history of tension headaches and recent increased stress. Pertinent positives: History of tension headaches, recent stress Pertinent negatives: Pain quality and severity differ from usual tension headaches

Final Diagnosis: Migraine without aura (newly diagnosed)

Rationale: The patient’s symptoms are most consistent with a migraine headache. The unilateral, throbbing pain accompanied by photophobia and nausea are characteristic of migraines. The severity and quality of pain differ from her usual tension headaches, suggesting this is a new onset of migraines.

Pathophysiological explanation: Migraines are believed to involve complex neurological processes, including activation of the trigeminovascular system and release of inflammatory neuropeptides. This leads to vasodilation and sensitization of pain pathways, resulting in the characteristic throbbing pain and associated symptoms (Goadsby et al., 2017).

Plan:

Diagnostic Plan:

No immediate imaging studies indicated based on current presentation and absence of red flags

Consider keeping a headache diary to track frequency, duration, and potential triggers

Treatment Plan:

Sumatriptan 50 mg orally at onset of migraine, may repeat in 2 hours if needed (not to exceed 200 mg in 24 hours)

Ondansetron 4 mg orally as needed for nausea

Continue over-the-counter ibuprofen 400 mg every 6 hours as needed for breakthrough pain

Patient Education:

Explain migraine diagnosis and management strategies

Instruct on proper use of sumatriptan, including potential side effects and when to seek medical attention

Discuss importance of identifying and avoiding potential triggers (e.g., certain foods, stress, irregular sleep)

Emphasize the importance of maintaining a regular sleep schedule and stress management techniques

Referral/Follow-up:

Follow-up appointment in 4 weeks to assess treatment efficacy and need for prophylactic therapy

Provide patient with resources for migraine support groups and educational materials

Health Maintenance:

Due for mammogram screening in 3 years (age 45) per USPSTF guidelines

Pap smear up to date, next due in 2 years

Encourage annual influenza vaccine

Dental check-up recommended within the next 6 months

Reference: The care provided aligns with the American Headache Society’s guidelines for acute migraine treatment (Ailani et al., 2021). The choice of sumatriptan as first-line therapy for acute migraine attacks is supported by strong evidence. The emphasis on patient education and lifestyle modifications is consistent with current best practices in migraine management.

References:

Ailani, J., Burch, R.C., Robbins, M.S., et al. (2021) ‘The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice’, Headache, 61(7), pp. 1021-1039.

Goadsby, P.J., Holland, P.R., Martins-Oliveira, M., et al. (2017) ‘Pathophysiology of Migraine: A Disorder of Sensory Processing’, Physiological Reviews, 97(2), pp. 553-622.

U.S. Preventive Services Task Force. (2023) ‘USPSTF A and B Recommendations’, Available at: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations (Accessed: 20 July 2024).