DeVry University, Chicago HANIM777 Arts & Hum Revised 20 Mini SOAP Notes

Revised 20 Mini SOAP Notes 1. ICD 10: G43.90 S: 36-year-old female present with complaints of a 3 frontal region headache for 3 days. Constant in nature with gradual increase in pain, progressive in degree of pain, no radiating pain into neck, posterior or temporal areas of head, described as “pressure” pain. No alleviating factors noted by patient. Alternating doses of Tylenol and Advil have not relieved headache. Headache present throughout the day and continues into the evening hours. Does not wake her from sleep. 7/10 in pain severity. Associated symptoms of nausea, 2 episodes of vomiting, sensitivity to light. Denies any recent head trauma, fever, dizziness, syncope, visual changes or ocular pain. Patient stated she has had migraines in the past. O: Vitals: Ht. 5’0, Wt. 175 lbs., BMI 34.2, T 98.6 F, BP 132/70, P 108, RR 16, Pox 99% on room air. Head: Normocephalic. No signs of head trauma, abrasions, lacerations, contusions. Eyes: White sclera. No conjunctival injection or subconjunctival hemorrhage. PERRLA and EOMI. Direct and consensual ocular reflexes intact. Fundoscopic exam revealed 1:2 cup to disc ratio and 4 arcades noted bilaterally. No retinal edema, hemorrhages, cotton wool patches or AV nicking noted. Fundoscopic exam limited by pupil restriction to light and patient discomfort. A: DX: Migraine Differential diagnosis: Tension headache, subarachnoid hemorrhage, epidural hematoma.