SOAP Note Unit 1 Case Study Name: Amanda Bright_
Typhon Encounter #: _____________________
NU___610:_________ Comprehensive:____Focused:____
Herzing University
S: SUBJECTIVE DATA
CC: The patient frequently complains of headaches.
HPI: The patient has been experiencing migraines since her teenage years, but
these headaches have become more debilitating recently. The pain
typically starts in the right temple or the back of the right eye, spreading
to the entire scalp over a few hours. She has these episodes once or twice
a month, and they can last for up to two days. The pain is described as a
sharp, throbbing sensation that gradually worsens and is accompanied by
severe nausea.
Her headaches are triggered by factors such as loud noises and movement.
She has been using over-the-counter medications like naproxen and
acetaminophen for relief. The only thing that seems to help is resting in a
dark, quiet room.
Additionally, a thorough history reveals that her mother also suffers from
migraines.
PMH: The only known medical history is that she has been dealing with these
headaches since her teenage years.
ALLERGIES The patient reports no drug allergies but does have seasonal allergies
and allergies to pet dander.
MEDICATIONS None
SH The patient is a first-year college student who denies any drug or alcohol
use; however, she is sexually active and reports using condoms.
FH Patient states a family history of the following.
Mother alive. History of migraines.
Fathered. No information provided.
Sister no information provided.
Brother, no information provided
Maternal. Grandmother, no information provided
Maternal. Grandfather: no information provided. Paternal. Grandmother
no information provided.
Paternal grandfather: no information provided.
HEALTH The patient confirms that she has completed all necessary summer
PROMOTION & medical visits, including routine check-ups and any recommended
MAINTENANC screenings. She feels reassured about her health status and is committed to
, SOAP Note Unit 1 Case Study Name: Amanda Bright_
Typhon Encounter #: _____________________
NU___610:_________ Comprehensive:____Focused:____
Herzing University
E maintaining her wellness through regular follow-ups and preventive care
measures.
ROS Constitutional The patient reports that they are not
experiencing any fever, chills, or night
(put N/A in sections sweats.
not completed day of
exam) Head Frequent debilitating headaches.
Eyes There are no visual changes, but there is
sensitivity to light (photophobia).
Ears, Nose, Mouth, Throat There are no noticeable masses, swollen
lymph nodes, or enlargement of the
thyroid.
Neck The patient reports no stiffness in the
neck.
Cardiovascular/Peripheral The patient denies experiencing
Vascular chest pain or palpitations.
Respiratory The patient denies experiencing
any shortness of breath or cough.
Breast N/A
Gastrointestinal Patient denies having abdominal
pain but reports experiencing
nausea and a headache. There
is no vomiting.
Genitourinary N/A
Musculoskeletal N/A
Integumentary N/A
Neurological Denies numbness, tingling,
weakness,
or mood changes
Psychiatric (screening tools: Ex: N/A
PHQ-9, MMSE, GAD-7)
Endocrine N/A
Hematologic/Lymphatic N/A
Allergic/Immunologic Denies drug allergies,
allergies to pet dander, and
seasonal allergies
Other N/A
O: OBJECTIVE DATA
HR: 62 RR: 17 BP: 112/70 Temp: 98.5
Typhon Encounter #: _____________________
NU___610:_________ Comprehensive:____Focused:____
Herzing University
S: SUBJECTIVE DATA
CC: The patient frequently complains of headaches.
HPI: The patient has been experiencing migraines since her teenage years, but
these headaches have become more debilitating recently. The pain
typically starts in the right temple or the back of the right eye, spreading
to the entire scalp over a few hours. She has these episodes once or twice
a month, and they can last for up to two days. The pain is described as a
sharp, throbbing sensation that gradually worsens and is accompanied by
severe nausea.
Her headaches are triggered by factors such as loud noises and movement.
She has been using over-the-counter medications like naproxen and
acetaminophen for relief. The only thing that seems to help is resting in a
dark, quiet room.
Additionally, a thorough history reveals that her mother also suffers from
migraines.
PMH: The only known medical history is that she has been dealing with these
headaches since her teenage years.
ALLERGIES The patient reports no drug allergies but does have seasonal allergies
and allergies to pet dander.
MEDICATIONS None
SH The patient is a first-year college student who denies any drug or alcohol
use; however, she is sexually active and reports using condoms.
FH Patient states a family history of the following.
Mother alive. History of migraines.
Fathered. No information provided.
Sister no information provided.
Brother, no information provided
Maternal. Grandmother, no information provided
Maternal. Grandfather: no information provided. Paternal. Grandmother
no information provided.
Paternal grandfather: no information provided.
HEALTH The patient confirms that she has completed all necessary summer
PROMOTION & medical visits, including routine check-ups and any recommended
MAINTENANC screenings. She feels reassured about her health status and is committed to
, SOAP Note Unit 1 Case Study Name: Amanda Bright_
Typhon Encounter #: _____________________
NU___610:_________ Comprehensive:____Focused:____
Herzing University
E maintaining her wellness through regular follow-ups and preventive care
measures.
ROS Constitutional The patient reports that they are not
experiencing any fever, chills, or night
(put N/A in sections sweats.
not completed day of
exam) Head Frequent debilitating headaches.
Eyes There are no visual changes, but there is
sensitivity to light (photophobia).
Ears, Nose, Mouth, Throat There are no noticeable masses, swollen
lymph nodes, or enlargement of the
thyroid.
Neck The patient reports no stiffness in the
neck.
Cardiovascular/Peripheral The patient denies experiencing
Vascular chest pain or palpitations.
Respiratory The patient denies experiencing
any shortness of breath or cough.
Breast N/A
Gastrointestinal Patient denies having abdominal
pain but reports experiencing
nausea and a headache. There
is no vomiting.
Genitourinary N/A
Musculoskeletal N/A
Integumentary N/A
Neurological Denies numbness, tingling,
weakness,
or mood changes
Psychiatric (screening tools: Ex: N/A
PHQ-9, MMSE, GAD-7)
Endocrine N/A
Hematologic/Lymphatic N/A
Allergic/Immunologic Denies drug allergies,
allergies to pet dander, and
seasonal allergies
Other N/A
O: OBJECTIVE DATA
HR: 62 RR: 17 BP: 112/70 Temp: 98.5
