Week 3 Problem-Focused SOAP Note Example
Submit a problem-focused SOAP note for grading. You must use an actual patient from your clinical practicum who presents with one or more chief complaints.
Use the format below for your SOAP note.
Use the current APA format to style your paper and cite your sources. Review the rubric for more information on how your assignment will be graded.
Problem-focused SOAP Note Format
Demographic Data
Age, and gender (must be HIPAA compliant)
Subjective
Chief Complaint (CC): A short statement about why they are there
History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment
Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance
Family Hx: any history of CA, DM, HTN, MI, CVA?
Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
Objective
Vital Signs
Physical findings listed by body systems, not paragraph form- Highlight abnormal findings
Assessment (the diagnosis)
At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each
Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation
Plan
Dx Plan (lab, x-ray)
Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)
Pt. Education, including specific medication teaching points
Referral/Follow-up
Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due (USPSTF guidelines)
Reference
Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.
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Problem-focused SOAP Note
Demographic Data: 42-year-old female
Subjective:
Chief Complaint (CC): “I’ve had a terrible headache for the past three days.”
History of Present Illness (HPI): 42-year-old female presents with a severe headache that began three days ago. The pain is localized to the right temporal region and described as throbbing and intense, rating 8/10 on a pain scale. The headache is constant but worsens with bright lights and loud noises. The patient reports nausea but no vomiting. Over-the-counter ibuprofen provides minimal relief. She denies visual disturbances, fever, or neck stiffness. The patient has a history of occasional tension headaches but states this pain is different and more severe than her usual headaches.
Past Medical History (PMH):
Hypothyroidism, diagnosed 5 years ago, well-controlled on levothyroxine
Seasonal allergies
No prior surgeries
Medications: Levothyroxine 100 mcg daily, loratadine 10 mg daily as needed
Allergies: None known
Immunizations: Up to date on Tdap and influenza vaccines
Family History:
Mother: Type 2 diabetes, hypertension
Father: Myocardial infarction at age 60
No family history of migraines or other neurological conditions
Social History:
Married, two children
Works as an elementary school teacher
Non-smoker, occasional alcohol use (1-2 glasses of wine per week)
Exercises 2-3 times per week (walking, yoga)
Balanced diet, but admits to increased stress and irregular meals in the past week due to end-of-year school activities
Review of Systems (ROS):
General: Denies fever, chills, or unexplained weight changes
HEENT: Reports photophobia, denies vision changes or ear pain
Cardiovascular: Denies chest pain or palpitations
Respiratory: Denies shortness of breath or cough
Gastrointestinal: Reports mild nausea, denies vomiting or changes in bowel habits
Musculoskeletal: Denies joint pain or muscle weakness
Neurological: Denies numbness, tingling, or weakness in extremities
Psychiatric: Reports feeling anxious due to pain and work stress
Objective:
Vital Signs:
Temperature: 37.0°C (98.6°F)
Blood Pressure: 128/82 mmHg
Heart Rate: 76 bpm
Respiratory Rate: 16 breaths/min
O2 Saturation: 99% on room air
Physical Examination:
General: Alert, oriented, in mild distress due to pain
HEENT:
Pupils equal, round, reactive to light
Extraocular movements intact
No conjunctival injection
Tympanic membranes clear bilaterally
Nasal passages patent, no discharge
Oropharynx clear, no erythema
Neck: Supple, no meningeal signs, no carotid bruits
Cardiovascular: Regular rate and rhythm, no murmurs
Respiratory: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, no organomegaly
Musculoskeletal: Full range of motion in neck, no tenderness
Neurological:
Cranial nerves II-XII intact
Strength 5/5 in all extremities
Sensation intact to light touch
Reflexes 2+ and symmetric
No pronator drift
Negative Romberg test
Assessment:
Differential Diagnoses:
Migraine without aura Rationale: Throbbing unilateral headache, photophobia, nausea, and no prior history of migraines. The pain is more severe than the patient’s usual tension headaches. Pertinent positives: Severe pain, photophobia, nausea Pertinent negatives: No visual aura, no family history of migraines
Tension-type headache Rationale: Patient has a history of tension headaches and recent increased stress. Pertinent positives: History of tension headaches, recent stress Pertinent negatives: Pain quality and severity differ from usual tension headaches
Final Diagnosis: Migraine without aura (newly diagnosed)
Rationale: The patient’s symptoms are most consistent with a migraine headache. The unilateral, throbbing pain accompanied by photophobia and nausea are characteristic of migraines. The severity and quality of pain differ from her usual tension headaches, suggesting this is a new onset of migraines.
Pathophysiological explanation: Migraines are believed to involve complex neurological processes, including activation of the trigeminovascular system and release of inflammatory neuropeptides. This leads to vasodilation and sensitization of pain pathways, resulting in the characteristic throbbing pain and associated symptoms (Goadsby et al., 2017).
Plan:
Diagnostic Plan:
No immediate imaging studies indicated based on current presentation and absence of red flags
Consider keeping a headache diary to track frequency, duration, and potential triggers
Treatment Plan:
Sumatriptan 50 mg orally at onset of migraine, may repeat in 2 hours if needed (not to exceed 200 mg in 24 hours)
Ondansetron 4 mg orally as needed for nausea
Continue over-the-counter ibuprofen 400 mg every 6 hours as needed for breakthrough pain
Patient Education:
Explain migraine diagnosis and management strategies
Instruct on proper use of sumatriptan, including potential side effects and when to seek medical attention
Discuss importance of identifying and avoiding potential triggers (e.g., certain foods, stress, irregular sleep)
Emphasize the importance of maintaining a regular sleep schedule and stress management techniques
Referral/Follow-up:
Follow-up appointment in 4 weeks to assess treatment efficacy and need for prophylactic therapy
Provide patient with resources for migraine support groups and educational materials
Health Maintenance:
Due for mammogram screening in 3 years (age 45) per USPSTF guidelines
Pap smear up to date, next due in 2 years
Encourage annual influenza vaccine
Dental check-up recommended within the next 6 months
Reference: The care provided aligns with the American Headache Society’s guidelines for acute migraine treatment (Ailani et al., 2021). The choice of sumatriptan as first-line therapy for acute migraine attacks is supported by strong evidence. The emphasis on patient education and lifestyle modifications is consistent with current best practices in migraine management.
References:
Ailani, J., Burch, R.C., Robbins, M.S., et al. (2021) ‘The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice’, Headache, 61(7), pp. 1021-1039.
Goadsby, P.J., Holland, P.R., Martins-Oliveira, M., et al. (2017) ‘Pathophysiology of Migraine: A Disorder of Sensory Processing’, Physiological Reviews, 97(2), pp. 553-622.
U.S. Preventive Services Task Force. (2023) ‘USPSTF A and B Recommendations’, Available at: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations (Accessed: 20 July 2024).
