Monroe College NURSING 812 Adult Assessment Migraine SOAP Note Chief Complaint: “I am here for an evaluation of my headache.” HPI: C.T. a 38 y/o white female presents to the clinic for an e... valuation of a headache. The pain is a throbbing sensation that is located in the temporal region and is an 8 on a scale of 1-10. The pain started a few hours ago while cooking breakfast. She has noted nausea with sensitivity to light. She has had headaches like this in the past. She states the headaches are usually less than one per week, but not as severe. There has not been any change in the frequency of her headache. She does not know of any aggravating factors. Ibuprofen and rest in a dark room resolves the pain. She denies and immunizations UTD. She received the flu vaccine 10/2013. No psychiatric history. Surgical HX: No surgical history. OBGYN: G-2 T-2 P-0 A-0 L-2 Medications: Ibuprofen 400 mg by mouth every 6 hours as needed for headache (last taken 6 hours ago) Lipitor 20 mg by mouth daily (last taken this morning) Amaryl 2 mg by mouth every morning (last taken this morning) Allergies: NKA Personal/social HX: Pt is married and lives with her husband and 2 children, all girls, ages 8 and 5. Lives in own home near her parent’s on rural property. Patient works approximately 20 minutes away at a car dealership as an accountant. Her husband is a self-employed contractor. They both graduated from LSU 15 years ago. C.T. states she works 2-3 days a week, 12-hour shifts. Family attends church on a regularly and has a good support system. The family is very active in the gym close to their home and eats healthy. C.T runs 4 miles at least 5 times a week. Drugs, Alcohol, or Smoking HX: No illegal drug use, no alcohol, or tobacco use. Family HX: Positive for diabetes and HTN in mother and father died of colon cancer 3 years ago at the age of 58. No family history of kidney disease, anemia, epilepsy, or mental illness. Source of information: Patient, seems reliable. SUBJECTIVE: Pt presented to the clinic today with a headache, that has a throbbing sensation located in the right temporal region. Rates the pain 8 on scale of 1-10. Pain started a few hours ago, and she has noted nausea with sensitivity to light. Has had headaches like this in the past, but usually less than one per week. Never this severe. No inciting factors and there has been no change in the frequency of her headaches. OTC analgesics help rid the headache. Review of Systems: ROS Constitution: Reports being “as healthy as she can be.” Denies fever, chills, recent weight gain or loss, weakness, or fatigue. States her last physical exam was in 2012. Skin, hair, & nails: Denies any changes in skin, hair, and nails. Denies rashes, lumps, sores or changes in hair on face or nails. No changes in size or color of moles. HEENT: head – Reports a headache with throbbing sensation right temporal region. Denies trauma, lightheadedness, or dizziness , eyes – Denies vision problems on a daily basis. Reports eyes bothering her when in light since her headache has started. Last eye exam one year ago with good report. No reports of any drainage, redness, or itching. No reports of double or blurred vision, spots, specks, or flashing lights. ears – Denies any ear pain or problems. Denies any drainage from ears. No tinnitus, vertigo, or infections. Hearing good, nose – Denies abnormal nasal conditions, no rhinorrhea, or nasal congestion. throat –Denies any throat problems. Good report at last dental exam 1 year ago, no dental caries or signs of gingivitis. No history of cold sores or canker sores. Thorax: Denies any swollen glands, lumps, or pain to neck. Lung disease, allergies, or asthma. Breast: Denies pain, discomfort, or discharge from nipples. Respiratory: No reports of coughing, congestion, wheezing, or shortness of breath. No history of lung disease, allergies, or asthma. Cardiovascular: No reports of chest pain, pressure, or tightness. No complaints of tachycardia, palpitations, or cyanosis. Reports high cholesterol. PVS: Denies extremity edema, coldness, leg cramps, varicose veins, or ulcers. Gastrointestinal: Diabetic diet. Reports nausea for the last couple of hours since her headache has come on. Denies vomiting, diarrhea, or abdominal pain. Eats well. Bowel movements regular. Denies history of jaundice, gallbladder, or liver disease. GU: Denies urinary frequency, hesitancy, incontinence, nocturia, flank pain, burning, or bleeding with urination. Denies history of urinary tract infections. ª Genital: Regular menstrual cycles. Last cycle was 2 weeks ago. No cramping and very little blood noted with cycles. Denies any bleeding between periods or after intercourse. No reports of vaginal discharge, itching, sores, lumps, or sexually transmitted diseases. No concerns about HIV infection. State’s that she and her husband use condoms. Musculoskeletal: Denies trauma or injury. [Show More]
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