SOAP Note Unit 1 Name:
Typhon Encounter #: 01
NU 610:7G Focused:_Assessment
Herzing University
S: SUBJECTIVE DATA
CC: Frequent headaches
HPI: A 19-year-old female presents with frequent headaches. She reports
having headaches that started when she was a teenager that has recently
become more debilitating. Episodes occur once or twice a month and
lasting up to 2 days. Pain begins in her right temple or back of the right
eye and radiates to the entire scalp over a few hours. Pain is described as a
sharp, throbbing sensation that gradually worsens and is associated with
severe nausea. Aggravating factors include loud noises and movement.
Alleviating factor is sleeping in a dark, quiet room. She has taken
over- the-counter medications like naproxen and acetaminophen
without any significant relief.
PMH: Headaches – started during teenage years
ALLERGIES Seasonal and Pet dander
NKDA
MEDICATIONS Naproxen
Tylenol
SH College freshman
Sexually active, uses condoms
Denies alcohol, illicit drug and tobacco use.
Last health visit was over the summer
Up-to-date on health maintenance for her age
FH Mother suffers from migraines
HEALTH Required for all SOAP notes:
PROMOTION &
MAINTENANC
E
ROS Constitutional Denies fever, chills, night sweats,
or weakness.
(put N/A in sections Head Headaches
not completed day of
exam) Eyes Photophobia
Ears, Nose, Mouth, Throat N/A
Neck Denies any neck stiffness
Cardiovascular/Peripheral Denies chest pain or palpitations
Vascular
Respiratory Denies shortness of breath or
cough
Breast N/A
Gastrointestinal Severe nausea associated with
, SOAP Note Unit 1 Name: Lezlee Gardiner
Typhon Encounter #: 01
NU 610:7G Focused:_Assessment
Herzing University
headaches
Genitourinary Last menses 4 weeks ago
Musculoskeletal Denies any weakness
Integumentary N/A
Neurological Headaches, denies any numbness
or tingling
Psychiatric (screening tools: Ex: Denies any changes in mood
PHQ-9, MMSE, GAD-7)
Endocrine N/A
Hematologic/Lymphatic N/A
Allergic/Immunologic Seasonal and pet dander
Other N/A
O: OBJECTIVE DATA
VITALS: HR: 62 RR: 17 BP: 112/70 Temp:
SpO2%: 99% Ht: 68 inches Wt: 151 lbs BMI: 23.0
RA
Age: 19 LMP: 4 weeks PAIN: 0-10
ago
PHYSICAL General Appearance Appears to be stated age
EXAM Head Normocephalic
Eyes PERRL, normal visual acuity using
(Pertinent data Snellen chart 20/20,
related to ENT, Mouth Ears: Tympanic membranes gray
presenting with adequate cone of light
problem or bilaterally. Weber and Rinne test
visit type. Put performed with normal bone and air
N/A in conduction.
sections not
Nose: No tenderness over sinuses.
completed day
of exam) Mouth/Throat: Mucous membranes
pink and dry. Palate and uvula at rest
are free of fasciculations, and
symmetry is noted when the patient
says “ah.” Positive gag reflex.
Neck No palpable masses, adenopathy or
thyroid enlargement
Cardiovascular/Peripheral Vascular Regular heart rate and rhythm
without murmurs, no edema noted
Respiratory Lungs clear bilaterally, no use of
accessory muscle
Breast N/A
Typhon Encounter #: 01
NU 610:7G Focused:_Assessment
Herzing University
S: SUBJECTIVE DATA
CC: Frequent headaches
HPI: A 19-year-old female presents with frequent headaches. She reports
having headaches that started when she was a teenager that has recently
become more debilitating. Episodes occur once or twice a month and
lasting up to 2 days. Pain begins in her right temple or back of the right
eye and radiates to the entire scalp over a few hours. Pain is described as a
sharp, throbbing sensation that gradually worsens and is associated with
severe nausea. Aggravating factors include loud noises and movement.
Alleviating factor is sleeping in a dark, quiet room. She has taken
over- the-counter medications like naproxen and acetaminophen
without any significant relief.
PMH: Headaches – started during teenage years
ALLERGIES Seasonal and Pet dander
NKDA
MEDICATIONS Naproxen
Tylenol
SH College freshman
Sexually active, uses condoms
Denies alcohol, illicit drug and tobacco use.
Last health visit was over the summer
Up-to-date on health maintenance for her age
FH Mother suffers from migraines
HEALTH Required for all SOAP notes:
PROMOTION &
MAINTENANC
E
ROS Constitutional Denies fever, chills, night sweats,
or weakness.
(put N/A in sections Head Headaches
not completed day of
exam) Eyes Photophobia
Ears, Nose, Mouth, Throat N/A
Neck Denies any neck stiffness
Cardiovascular/Peripheral Denies chest pain or palpitations
Vascular
Respiratory Denies shortness of breath or
cough
Breast N/A
Gastrointestinal Severe nausea associated with
, SOAP Note Unit 1 Name: Lezlee Gardiner
Typhon Encounter #: 01
NU 610:7G Focused:_Assessment
Herzing University
headaches
Genitourinary Last menses 4 weeks ago
Musculoskeletal Denies any weakness
Integumentary N/A
Neurological Headaches, denies any numbness
or tingling
Psychiatric (screening tools: Ex: Denies any changes in mood
PHQ-9, MMSE, GAD-7)
Endocrine N/A
Hematologic/Lymphatic N/A
Allergic/Immunologic Seasonal and pet dander
Other N/A
O: OBJECTIVE DATA
VITALS: HR: 62 RR: 17 BP: 112/70 Temp:
SpO2%: 99% Ht: 68 inches Wt: 151 lbs BMI: 23.0
RA
Age: 19 LMP: 4 weeks PAIN: 0-10
ago
PHYSICAL General Appearance Appears to be stated age
EXAM Head Normocephalic
Eyes PERRL, normal visual acuity using
(Pertinent data Snellen chart 20/20,
related to ENT, Mouth Ears: Tympanic membranes gray
presenting with adequate cone of light
problem or bilaterally. Weber and Rinne test
visit type. Put performed with normal bone and air
N/A in conduction.
sections not
Nose: No tenderness over sinuses.
completed day
of exam) Mouth/Throat: Mucous membranes
pink and dry. Palate and uvula at rest
are free of fasciculations, and
symmetry is noted when the patient
says “ah.” Positive gag reflex.
Neck No palpable masses, adenopathy or
thyroid enlargement
Cardiovascular/Peripheral Vascular Regular heart rate and rhythm
without murmurs, no edema noted
Respiratory Lungs clear bilaterally, no use of
accessory muscle
Breast N/A
