*NURSING > SOAP NOTE > SOAP note #2: Emily Green (I- Human patient) (All)

SOAP note #2: Emily Green (I- Human patient)

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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. [Show More]

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