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The patient presented with a headache that began after a motor vehicle collision. A physical exam found no abnormalities. The most likely diagnosis was determined to be a post-traumatic headache. An MRI was scheduled to rule out other potential causes. The patient was prescribed medications for headache relief and counseled on the expected course. Health maintenance advice addressed immunizations, diet, exercise, and routine screenings.

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Razan Haimouny
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239 views5 pages

Soap Note Template 03

The patient presented with a headache that began after a motor vehicle collision. A physical exam found no abnormalities. The most likely diagnosis was determined to be a post-traumatic headache. An MRI was scheduled to rule out other potential causes. The patient was prescribed medications for headache relief and counseled on the expected course. Health maintenance advice addressed immunizations, diet, exercise, and routine screenings.

Uploaded by

Razan Haimouny
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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SOAP NOTE

PATIENT PROFILE/IDENTIFYING DATA


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Problem List:
Headache onset 8/28/01

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SUBJECTIVE

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DIFFERENTIAL DIAGNOSES/RATIONALE:
1. ______________________________________________________________
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2. ______________________________________________________________
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3. ______________________________________________________________
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4. ______________________________________________________________
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5. ______________________________________________________________
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HPI:
Past Medical History:

Social History:
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ROS:
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Pertinent positives/negatives:
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OBJECTIVE:

Vital Signs: Weight 179 lbs, Height 65 inches, Temperature 99.2 orally, Pulse
76, Resp 20, BP 114/72.

Physical Exam:
Cooperative, calm patient with clear and appropriate speech and language.
Head normocephalic, atraumatic, no hematomas, or tenderness to palpation.
Neck supple with full ROM. Eyes symmetric, lids symmetric, conjunctiva clear
without redness. Visual fields full to confrontation. EOM’s full, no ptosis.
PERRLA, optic discs sharp without papilledema, macula intact. Facial sensation
intact, facial motor movement symmetric. Hearing intact to whispered words.
External ears without trauma or drainage. Auricle, tragus, mastoid nontender to
palpation. Ear canal and tympanic membrance visualized, landmarks intact.
Gag reflex and tongue movement intact and full. No lymphadenopathy. Moves
all extremities 5/5 strength. Coordination intact with finger to nose testing.
Sensation intact to pin prick and touch throughout. Reflexes 2+ throughout, with
plantar responses downgoing. Romberg testing negative.

DDX:
1. Tension headache- pertinent positives/negatives same as above. Probably
not likely since this headache began after MVC and she denies stress and
tension.
2. Brain tumor- pertinent positives/negatives same as above. Also, no
papilledema noted or other signs of increased intracranial pressure. Not likely
since headache started after MVC, but will keep this diagnosis on back
burner, to keep in mind.
3. Meningitis- pertinent positives from examining this patient are none, she has
no meningismus or nuchal rigidity, no fever, confusion, irritability and no
photophobia, and the headache has been present for several weeks, so if it is
meningitis, she would have been much sicker, sooner. Meningitis is usually
acute, developing over 24-36 hours with fever, h/a, vomiting, nuchal rigidity,
lethargy (Meredith & Horan, 2000). This diagnosis is not likely.
4. Post-traumatic headache- positives/negatives same as above. This is the
most likely diagnosis at this point.

ASSESSMENT/PLAN

1. Post-traumatic headache-most likely diagnosis based on all above information


(ICD code for general headache is 784.0, and she will be coded as such until
further evaluation). Post concussional syndrome (ICD code 310.02) is common
and has varied severity. The patient may not have lost consciousness (as in this
patient) but suffered trauma (can be minimal as in this patient). The triad of
symptoms includes headaches, dizziness, and poor concentration (Patten,
1996). To further evaluate her, an MRI of the brain was scheduled for the next
day, in order to rule out other causes of headache. This is essential in this case,
because a subdural hematoma or brain tumor could be life threatening. Once
these are ruled out, her code will be post concussional syndrome (310.02).
Headaches, post trauma, (tension type or migraine type) can be treated with the
usual symptomatic/prophylactic medications. Most patients improve after 3
months, and reassurance serves maximum benefit (Goetz, 1999). She was
counseled on the length of time of these headaches, sometimes weeks to
months, and encouraged to try Midrin which she already has the prescription for,
to try to alleviate the headaches when they increase in severity. She was also
prescribed Motrin 800mg TID, and told to take the Midrin for breakthrough severe
pain. She verbalized understanding and was relieved that a scan would be done
to rule out serious problems.
She will followup the following week to review the MRI results (of course she will be
notified immediately of any serious findings that require immediate treatment) and
evaluate how her headaches are responding to the Motrin and Midrin.

1. Health Maintenance-For E.S.’s age group, one of the major concerns is


immunization updates. Her DTP, MMR, varicella, polio vaccines are probably
already up to date, but need to be double checked to make sure there are none
missing in her history. Hepatitis B would be recommended if she is going into
health care in her college courses, or if she has close contact with high risk
individuals. Meningitis vaccine should be offered, especially because she is a
college student and meningitis is a high risk among students. Need to establish
when her last pelvic exam with pap smear was performed and stress that she get
regular pap smears, atleast every 3 years (US Preventive Services Task Force
recommendations-Clinician’s Handbook of Preventive Services, 1998). This
testing should begin at the age she begins intercourse, or at age 18. Low
socioeconomic status or multiple partners would indicate need for more frequent
pap smears. STD prevention and contraception issues would also need to be
addressed. Use of seatbelts while driving needs to be stressed as well as helmet
use with bikeriding, motorcycle riding, or ATV use. Diet should be limited fats and
cholesterol, while maintaining caloric intake, emphasizing fruits, vegetables, and
grains. Regular physical activity and adequate calcium intake should also be
encouraged (Uphold & Graham, 1998).
With E.S. in particular, she has a pap smear in the last year, and is not
presently sexually active, but stated that she would use condoms for STD
prevention and would seek contraception if she were to become sexually active.
Her immunizations are up to date, and she was reminded of the meningitis
vaccine available at ECU for students. She uses seatbelts regularly. She does
not ride a bike or motorcycle/ATV, but was encouraged to wear a helmet if she
were to do so. Her diet consists of mostly balanced meals, with alot of snacks in
between, sodas and chips. She was encouraged to limit sodas/chips as much as
possible and try more healthy snacks such as fruits/vegetables. She has not
exercised at all this semester, as opposed to the summer when she worked out
regularly at the ECU gym. She was encouraged to try to get back into exercising
as able, when her headaches improve.

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