SOAP NOTE 2 2
A 22-year-old female college student presented to the clinic setting today unaccompanied. The
patient states she has a throbbing left sided headache that is not relieved by Tylenol at home. She
reports o
...
SOAP NOTE 2 2
A 22-year-old female college student presented to the clinic setting today unaccompanied. The
patient states she has a throbbing left sided headache that is not relieved by Tylenol at home. She
reports one similar episode with differing symptoms and states she otherwise overall healthy.
Subjective:
Chief complaint:
Headache
History of present illness:
A 22-year-old female college student who states she has a throbbing left sided headache
that is not relieved by Tylenol at home. The patient states is experiencing light sensitivity and
noise sensitivity. She states she has had one episode similar to this a year ago with flashes of
light and “problems seeing in certain directions.” Her head pain can be relieved by lying down in
a dark, quiet room. Emily states she is experiencing nausea with the head pain and rates this pain
8/10. She has had more stress than usual with school, relationships, poor eating and sleeping. She
states her mother and sister both have had similar episodes.
Past medical history:
Illness/ hospitalizations/ surgeries. States generally in good health. No history of
hospitalizations. Denies past surgeries
Medications: Birth Control
Allergies: no known allergies
Preventative Health: She has had regular well checks.
Social history: Emily is a college student who denies smoking tobacco and drinks red wine
occasionally on the weekends. She is not married and recently went through a break-up with her
boyfriend. She denies any illicit drug use.
Family history:
Mother: migraines
Sister: migraines
Review of Systems
General/ Constitutional
Complains of. Headache and nausea
Denies. Denies visual changes, vomiting, gait imbalances, or nuchal rigidity
Head, Eyes, Ears, Nose, Throat, Neck.
Complains of. Left sided temporal pain. Complains of sensitivity to light and sound.
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