Case Study:
Emily Johnson is a 42-year-old female presenting for her annual wellness check-up. She has been experiencing occasional headaches and fatigue for the past three months. Emily works as a high school teacher and has noticed increased stress levels lately. She has a family history of hypertension and breast cancer. Emily is concerned about her weight gain over the past year and wants to discuss options for improving her overall health.
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Date of Encounter: 07/17/2024
Preceptor/Clinical Site: [To be filled]
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C
SOAP Note # 1 Main Diagnosis: Z00.00 – Encounter for general adult medical examination with abnormal findings
PATIENT INFORMATION
Name: Emily Johnson
Age: 42 years
Gender at Birth: Female
Gender Identity: Female
Source: Patient
Allergies: Penicillin (hives)
Current Medications: Multivitamin daily, Ibuprofen 400mg PRN for headaches
S: SUBJECTIVE DATA
Chief Complaint: “I’m here for my annual check-up, but I’ve been having headaches and feeling tired lately.”
History of Present Illness (HPI):
Emily Johnson, a 42-year-old female, presents for her annual wellness check-up. She reports experiencing occasional headaches and fatigue for the past three months. The headaches occur 2-3 times per week, typically in the afternoon, and are described as a dull ache across the forehead (6/10 on pain scale). Headaches are partially relieved by over-the-counter Ibuprofen and rest. Fatigue is most noticeable at the end of the workday. She denies any visual disturbances, nausea, or vomiting associated with the headaches. Emily attributes these symptoms to increased stress at work. She also expresses concern about a 10-pound weight gain over the past year.
Past Medical History:
Seasonal allergies
Appendectomy (age 15)
No history of chronic illnesses such as hypertension, diabetes, or cancer.
Medications:
Multivitamin daily
Ibuprofen 400mg PRN for headaches (2-3 times per week)
Allergies: Penicillin (hives)
Immunizations:
COVID-19 vaccine series completed (1/2022)
Influenza vaccine annually (last received 10/2023)
Tdap booster (5/2019)
HPV series completed (age 26)
Family History:
Mother: Hypertension (diagnosed at age 50), alive
Father: Type 2 Diabetes (diagnosed at age 55), alive
Maternal aunt: Breast cancer (diagnosed at age 48), in remission
Social History:
Occupation: High school teacher
Marital status: Married with two children (ages 10 and 8)
Tobacco use: Never smoker
Alcohol use: 1-2 glasses of wine per week
Exercise: Walks 20 minutes, 2-3 times per week
Diet: Reports increased consumption of processed foods and decreased fruit/vegetable intake over the past year
Sleep: 6-7 hours per night, often feels unrested
Stress level: Rates as 7/10, primarily work-related
Review of Systems:
Constitutional: Reports fatigue, denies fever, chills, or unexpected weight changes
HEENT: Reports headaches, denies vision changes, hearing issues, or sore throat
Cardiovascular: Denies chest pain, palpitations, or edema
Respiratory: Denies shortness of breath, cough, or wheezing
Gastrointestinal: Occasional heartburn, denies abdominal pain, nausea, or changes in bowel habits
Genitourinary: Denies dysuria, urgency, or abnormal vaginal discharge
Musculoskeletal: Reports occasional lower back pain after prolonged standing, denies joint pain or swelling
Neurological: Denies numbness, tingling, or loss of consciousness
Psychiatric: Reports increased stress, denies depression or anxiety
Skin: Denies rashes or concerning lesions
Endocrine: Denies excessive thirst or frequent urination
Hematologic: Denies easy bruising or bleeding
O: OBJECTIVE DATA
Vital Signs:
BP: 138/88 mmHg (repeated: 136/86 mmHg)
HR: 78 bpm
RR: 16 breaths/min
Temp: 98.6°F (37°C)
SpO2: 99% on room air
Height: 165 cm (5’5″)
Weight: 75 kg (165 lbs)
BMI: 27.5 kg/m²
General Appearance: Well-groomed female, alert and oriented, in no acute distress
HEENT:
Head: Normocephalic, atraumatic
Eyes: PERRLA, EOMs intact, conjunctivae clear
Ears: TMs intact bilaterally, no erythema or exudate
Nose: No discharge or congestion
Throat: Oral mucosa moist, no erythema or exudates
Neck: Supple, no lymphadenopathy, thyroid not enlarged
Cardiovascular: Regular rate and rhythm, S1 and S2 normal, no murmurs, rubs, or gallops
Respiratory: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi
Gastrointestinal: Soft, non-tender, non-distended, normal bowel sounds, no organomegaly
Musculoskeletal: Full ROM in all joints, strength 5/5 in all extremities, no edema
Neurological: CN II-XII intact, sensory and motor function intact, normal gait
Skin: Warm, dry, no rashes or lesions
Psychiatric: Affect appropriate, mood euthymic
A: ASSESSMENT
R51 – Headache
Emily presents with a 3-month history of tension-type headaches, likely related to increased stress. The International Headache Society defines tension-type headaches as recurrent episodes of headache lasting minutes to days, typically bilateral, pressing or tightening in quality, of mild to moderate intensity, and not aggravated by routine physical activity (Headache Classification Committee of the International Headache Society, 2018).
R53.83 – Other fatigue
Patient reports increased fatigue, possibly related to stress, inadequate sleep, or potential underlying medical conditions.
E66.3 – Overweight
BMI of 27.5 kg/m² falls within the overweight category. Recent weight gain of 10 pounds over the past year.
Z71.3 – Dietary counseling and surveillance
Patient reports increased consumption of processed foods and decreased intake of fruits and vegetables.
R03.0 – Elevated blood pressure reading, without diagnosis of hypertension
BP readings of 138/88 mmHg and 136/86 mmHg are elevated. According to the American College of Cardiology/American Heart Association guidelines, this falls under the category of Stage 1 hypertension (Whelton et al., 2018).
Z71.89 – Other specified counseling
Patient reports high stress levels (7/10) primarily related to work.
P: PLAN
Headache and Fatigue:
Recommend headache diary to track frequency, duration, and potential triggers
Discuss stress management techniques: mindfulness, deep breathing exercises
Encourage regular sleep schedule aiming for 7-9 hours per night
Order CBC, TSH, and Vitamin D levels to rule out underlying causes of fatigue
Blood Pressure Management:
Educate on DASH diet and sodium restriction
Encourage increased physical activity: aim for 150 minutes of moderate-intensity exercise per week
Schedule follow-up BP check in 2 weeks
If BP remains elevated, consider 24-hour ambulatory BP monitoring
Weight Management and Nutrition:
Refer to nutritionist for dietary counseling
Recommend Mediterranean diet pattern
Set goal for 5-10% weight loss over 6 months
Encourage use of a food diary app for tracking intake
Preventive Care:
Order lipid panel and fasting glucose
Perform clinical breast exam; refer for screening mammogram given family history of breast cancer
Ensure cervical cancer screening is up to date
Stress Management:
Refer to employee assistance program for stress management resources
Discuss importance of work-life balance
Consider referral to counselor if stress symptoms persist or worsen
Follow-up:
Schedule follow-up visit in 1 month to review lab results and reassess symptoms
Encourage patient to call or schedule earlier appointment if symptoms worsen
Patient Education: Provided education on lifestyle modifications for blood pressure control, weight management strategies, and stress reduction techniques. Discussed warning signs that should prompt earlier follow-up.
References:
Headache Classification Committee of the International Headache Society. (2018). The International Classification of Headache Disorders, 3rd edition. Cephalalgia, 38(1), 1-211.
Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., … & Wright, J. T. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 71(19), e127-e248.
