IHUMAN CASE STUDY-EMILY GREEN

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IHUMAN CASE STUDY-EMILY GREEN SOAP NOTE Clinical SOAP NOTE: IHuman Emily Green I. Subjective Data A. Chief Complaint (CC): “Headache” B. History of Present Illness (HPI): Mrs. Green is a 22... years old full-time student at a community college who presented to the clinic with cc of a headache. She reports her headache started yesterday morning, lasting about 30 hours. It is a worsening, more frequent, pulsating/throbbing, and rated an 8/10. The headache started at the left temple and radiates to her whole head. Associated symptoms include nausea that occurs with worsening headache. Aggravating factors include loud noise, light, red wine, and caffeine. Alleviating factors laying down in a quite dark room. Pt. has been taking Tylenol every 4 hours with little relief. Pt report recent increase in stress and decrease sleep. She denies SOB, chest pain, dizziness, seizure, memory issues, head trauma, visuals changes, neck stiff, and falls C. Last Menstrual Period: (LMP- if applicable): forgot to ask D. Allergies: NKA E. Past Medical History: Non contributary F. Family History: Father: HTN. [Show More]

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