Answer for NUR 600 Assignment 11.2: Writing a SOAP Note
Patient Information:
Initials: D.P
Age: 23 years
Sex: Male
Race: African American
Subjective History
CC: “Regular headaches.”
HPI:
D.P is a 23-year-old AA male patient who presents with complaints of headaches that began eight days ago. He states that the headaches are intermittent and diffuse all over the head. The pain occurs for about 10-30 minutes. The headache is described as a throbbing pain that has the greatest intensity and pressure above the eyes. He states that the pain spreads to the nose, cheekbones, and jaw. The headache is aggravated by activity and bending over and, to some extent, relieved by rest and taking Tylenol. He denies experiencing nausea, vomiting, photophobia, or phonophobia associated with the headache. He rates the headache as 5/10 on the pain scale. D.P. reports that the headache often interferes with his activities.
Current Medications: OTC Motrin 400 mg PRN to alleviate headaches.
Allergies: Allergic to smoke and air sprays, causing sneezing. No known drug allergies.
PMHx: D.P. has a history of Chronic sinusitis.
Social Hx: D.P. is an intern at an Insurance firm, and he graduated four months ago with a Bachelor’s in Finance. He lives in the college hostels while in school and with his parents and two younger siblings on holidays. His hobbies include reading novels, writing articles, and painting. He is financed by his two parents and gets some money from his part-time job. K.M. admits taking alcohol, 3-4 beers on weekends, but denies smoking or using other illicit drugs.
Family Hx: Paternal grandfather had pancreatic cancer. Father has Diabetes. Sibling alive and well.
ROS:
General: Denies fatigue, weight changes, fever, or chills.
HEENT: Positive for headache, facial pain, facial pressure, and rhinorrhea. Denies visual changes, photophobia, phonophobia, hearing loss, loss of taste, or swallowing difficulties.
Neck: No neck pain or stiffness.
Skin: No skin color changes, itching, rashes, or lesions.
Cardiovascular: No edema, palpitations, chest pain, or exertional dyspnea.
Respiratory: No cough, sputum production, chest pain, or shortness of breath.
Gastrointestinal: No appetite changes, epigastric pain, abdominal pain, bowel changes, or rectal bleeding.
Genitourinary: No penile discharge, dysuria, blood in urine, or urinary urgency/frequency.
Neurological: Positive for headache. No dizziness, black spells, altered conscious levels, or tingling sensations.
Musculoskeletal: No muscle pain, back pain, joint pain, or stiffness.
Hematologic: No history of bleeding gums, anemia, or blood transfusion.
Lymphatic’s: Negative for lymph node enlargement.
Psychiatric: No anxiety or depressive symptoms.
Endocrinologic: No heat/cold intolerance, increased urine production, acute thirst, or excessive hunger.
Allergies: Allergic to smoke and air sprays.
Objective History
Physical Exam:
Vital Signs: BP- 118/76 mm Hg; Resp- 22; PR- 88; Temp- 98.78 F
Weight- 137 lbs.; Height- 5’5; BMI- 22.8
General: The client is well-groomed and appropriately dressed for the weather. He is alert and in no acute pain or distress. Oriented to person, place, and time; maintains eye contact and has clear speech.
HEENT: Head: Atraumatic and normocephalic. Hair is black, well-distributed, with no scalp tenderness. Tenderness on the cheekbones and jawline. Eyes: Sclera is white and conjunctiva pink. PERRLA with no excessive lacrimation. Tenderness on the orbital area and frontal sinus are palpable. Ears: T.M.s clear. Minimal pus present but with no ear discharge. No mastoid bone inflammation. Nose: Rhinorrhea with clear nasal discharge. Tenderness on the bridge of the nose. Throat: Mucous membranes pink and moist. Tonsillar glands are non-erythematous.
Neck: Full ROM of the neck. The trachea is midline. The thyroid gland is normal on palpation.
Respiratory: Respirations smooth, chest rise and falls in unison on inspiration and expiration. Lungs clear on auscultation.
Cardiovascular: No edema or jugular vein distension. Capillary refill- 2 seconds. S1 and S2 are present. Gallop sounds, systolic murmurs, and frictions rub absent.
Neurological: Speech is clear with normal volume and rate. C.N.s intact. Muscle strength 5/5.
