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Shadow Health - Neurological SOAP - Tina Jones
SUBJECTIVE
CC “Well, I got into a little fender bender a week ago and I've been getting these headaches ever
since. And my neck is sore too.”
HPI - Tina Jones: 28 year old African American woman. Pt A&O x3 and reliable; able to
provide her health history and CC. Car accident happened a little over a week ago going about
15 MPH in a parking lot. Confirmed wearing seatbelt and in the front passenger seat. Denied
drugs or alcohol involvement. C/O headaches & stiff, painful neck that started 2 days after the
accident, 5 days ago. Headaches feel different than previous. Reported 1 a day; headaches occur
daily at random times lasting about 1-2 hrs. Reported “dull ache” pain crown and back of head.
Denied sharp pain or pain waking her at night. Current neck pain, 3/10, most severe headache,
4/10. Reported pain in the neck goes up to her head. Denied LOC. No loss of balance. Denied
triggers prior to onset. Denied tightness, throbbing, and sharpness. Denied dysphagia, dysphasia.
Denied rapid crescendo. Denied photophobia and phonophobia. Denied N&V and dizziness.
Denied vision changes after the accident. Denied numbness or tingling. Denied depression and
irritability. Take 2 tabs of acetaminophen immediately upon onset of headache, positive effect
the rest of the day. Last headache, yesterday afternoon.
PMH:
Asthma dx at 2.5 yrs old. Type 2 diabetes dx at 24 yrs old. ER visit 6 months ago for wound to R
foot; healed. Denied past surgeries. Denied hx of neurological deficits, fainting, seizures,
Alzheimer’ss and Parkinson’s. Denied h/o psychological disorders. Drug allergy, Penicillin -
breaks out into hives (last episode, was a child) Environmental allergy, cats and dust causing
itchy eyes, sneezing, wheezing, triggers asthma. No known food allergy and no known latex
allergy
FH:
Denied family history seizures, headaches, and neurological issues
Mother (age 50)-high cholesterol and blood pressure. Alive.
Father (age 58)-high blood pressure and cholesterol, diabetes. Died in a car accident 2 years ago.
Maternal grandmother (73)- high blood pressure and cholesterol. Died of a stroke 5 years ago.
Maternal grandfather (80)-high blood pressure and cholesterol. Died of a heart attack.
Paternal grandmother (82)-high blood pressure and high cholesterol. Alive.
Paternal grandfather (mid 60s)- colon cancer, high blood pressure, diabetes. Died of colon
cancer.
Sister (14)- asthma, allergies currently flaring, hay fever symptoms with runny nose and a lot of
sneezing
This study source was downloaded by 1827175 from cliffsnotes.com on 01-08-2026 19:47:50 GMT -06:00
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Brother (25)-overweight
Social Determinant of health:
Has health insurance from her current job; unaware of what’s covered. Reports having care
insurance. Denied that the accident placed extra burden on her financially. Reported living close
to grocery store and fresh food
Medications
Flovent inhaler 2 puffs BID daily for routine treatment of asthma (current) last dose this AM
Proventil Inhaler 90 mcg 2-3 puffs Q4-6hr prn for asthma exacerbations (current) Last dose 8
months ago
Advil 200 mg PO TID for menstrual cramping (current) last dose 1 month ago
Tylenol 500 mg PO PRN for headaches (current) last dose yesterday afternoon
Metformin – dosage unknown (Discontinued by patient 4 years ago)
Patient denies taking vitamins or herbal supplements
Social History
Currently working as a supervisor at Mid-American Copy & Ship and has worked there since
high school. Has insurance through her job. Finishing up bachelor’s degree in accounting.
Denied finances being a barrier to healthcare. Never married and currently not dating; reported is
a happy single woman. No children, denied past pregnancy and abortions. Currently obtaining a
bachelor degree in accounting. Currently lives at home with mother and sister. Denied exposure
to communicable diseases. Smoked marijuana with friends in the past; last smoked when she was
20 or 21 years old but stopped as it bothered her asthma. Social drinker, rum and coke, on the
weekends and denies drinking during the week; last drink was 2 weeks ago. Denied smoking or
use of any tobacco, vaping, and e-cigs but is exposed to second-hand smoke as friends smoke.
Not sexually active; had three partners in the past. Discontinued birth control as she is no longer
sexually active. denied STDs. Attends Bible group and church weekly at first baptist. Hobbies
include reading books and watching TV shows and documentaries. To relax, dance or go to bars
with friends. Volunteers at Habitat for Humanity but helping paint. T2DM, stays away from most
sweets and drinks diet soda up to 4 times and 6-8 cups of water. Eats three meals a day and
doesn't monitor salt intake. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich
with chips, dinner is a homemade meal of meat and vegetables, and snacks are French fries or
pretzels. She denies coffee & energy drink intake but does drink diet cola on a regular basis.
Denied having an exercise routine, on her feet all day at work.
Health Maintenance: Last health exam two years ago. Last visit to the Shadow Health Clinic was
3 months ago due to back pain. Last PPD was two years ago, negative. Last Flu vaccine 5-6
years ago. Tetanus booster last year. One dose of meningococcal vaccine at 19 yrs old. Last eye
exam in childhood. Last dental exam 3 years ago.
This study source was downloaded by 1827175 from cliffsnotes.com on 01-08-2026 19:47:50 GMT -06:00
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Shadow Health - Neurological SOAP - Tina Jones
SUBJECTIVE
CC “Well, I got into a little fender bender a week ago and I've been getting these headaches ever
since. And my neck is sore too.”
HPI - Tina Jones: 28 year old African American woman. Pt A&O x3 and reliable; able to
provide her health history and CC. Car accident happened a little over a week ago going about
15 MPH in a parking lot. Confirmed wearing seatbelt and in the front passenger seat. Denied
drugs or alcohol involvement. C/O headaches & stiff, painful neck that started 2 days after the
accident, 5 days ago. Headaches feel different than previous. Reported 1 a day; headaches occur
daily at random times lasting about 1-2 hrs. Reported “dull ache” pain crown and back of head.
Denied sharp pain or pain waking her at night. Current neck pain, 3/10, most severe headache,
4/10. Reported pain in the neck goes up to her head. Denied LOC. No loss of balance. Denied
triggers prior to onset. Denied tightness, throbbing, and sharpness. Denied dysphagia, dysphasia.
Denied rapid crescendo. Denied photophobia and phonophobia. Denied N&V and dizziness.
Denied vision changes after the accident. Denied numbness or tingling. Denied depression and
irritability. Take 2 tabs of acetaminophen immediately upon onset of headache, positive effect
the rest of the day. Last headache, yesterday afternoon.
PMH:
Asthma dx at 2.5 yrs old. Type 2 diabetes dx at 24 yrs old. ER visit 6 months ago for wound to R
foot; healed. Denied past surgeries. Denied hx of neurological deficits, fainting, seizures,
Alzheimer’ss and Parkinson’s. Denied h/o psychological disorders. Drug allergy, Penicillin -
breaks out into hives (last episode, was a child) Environmental allergy, cats and dust causing
itchy eyes, sneezing, wheezing, triggers asthma. No known food allergy and no known latex
allergy
FH:
Denied family history seizures, headaches, and neurological issues
Mother (age 50)-high cholesterol and blood pressure. Alive.
Father (age 58)-high blood pressure and cholesterol, diabetes. Died in a car accident 2 years ago.
Maternal grandmother (73)- high blood pressure and cholesterol. Died of a stroke 5 years ago.
Maternal grandfather (80)-high blood pressure and cholesterol. Died of a heart attack.
Paternal grandmother (82)-high blood pressure and high cholesterol. Alive.
Paternal grandfather (mid 60s)- colon cancer, high blood pressure, diabetes. Died of colon
cancer.
Sister (14)- asthma, allergies currently flaring, hay fever symptoms with runny nose and a lot of
sneezing
This study source was downloaded by 1827175 from cliffsnotes.com on 01-08-2026 19:47:50 GMT -06:00
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Brother (25)-overweight
Social Determinant of health:
Has health insurance from her current job; unaware of what’s covered. Reports having care
insurance. Denied that the accident placed extra burden on her financially. Reported living close
to grocery store and fresh food
Medications
Flovent inhaler 2 puffs BID daily for routine treatment of asthma (current) last dose this AM
Proventil Inhaler 90 mcg 2-3 puffs Q4-6hr prn for asthma exacerbations (current) Last dose 8
months ago
Advil 200 mg PO TID for menstrual cramping (current) last dose 1 month ago
Tylenol 500 mg PO PRN for headaches (current) last dose yesterday afternoon
Metformin – dosage unknown (Discontinued by patient 4 years ago)
Patient denies taking vitamins or herbal supplements
Social History
Currently working as a supervisor at Mid-American Copy & Ship and has worked there since
high school. Has insurance through her job. Finishing up bachelor’s degree in accounting.
Denied finances being a barrier to healthcare. Never married and currently not dating; reported is
a happy single woman. No children, denied past pregnancy and abortions. Currently obtaining a
bachelor degree in accounting. Currently lives at home with mother and sister. Denied exposure
to communicable diseases. Smoked marijuana with friends in the past; last smoked when she was
20 or 21 years old but stopped as it bothered her asthma. Social drinker, rum and coke, on the
weekends and denies drinking during the week; last drink was 2 weeks ago. Denied smoking or
use of any tobacco, vaping, and e-cigs but is exposed to second-hand smoke as friends smoke.
Not sexually active; had three partners in the past. Discontinued birth control as she is no longer
sexually active. denied STDs. Attends Bible group and church weekly at first baptist. Hobbies
include reading books and watching TV shows and documentaries. To relax, dance or go to bars
with friends. Volunteers at Habitat for Humanity but helping paint. T2DM, stays away from most
sweets and drinks diet soda up to 4 times and 6-8 cups of water. Eats three meals a day and
doesn't monitor salt intake. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich
with chips, dinner is a homemade meal of meat and vegetables, and snacks are French fries or
pretzels. She denies coffee & energy drink intake but does drink diet cola on a regular basis.
Denied having an exercise routine, on her feet all day at work.
Health Maintenance: Last health exam two years ago. Last visit to the Shadow Health Clinic was
3 months ago due to back pain. Last PPD was two years ago, negative. Last Flu vaccine 5-6
years ago. Tetanus booster last year. One dose of meningococcal vaccine at 19 yrs old. Last eye
exam in childhood. Last dental exam 3 years ago.
This study source was downloaded by 1827175 from cliffsnotes.com on 01-08-2026 19:47:50 GMT -06:00
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