Case study
Instructions
· Review the following case study.
· Construct a subjective data set for the case study on the provided SOAP note template from the information provided.
· Structure the subjective data set on the SOAP note template in the format provided in your lecture materials.
· Submit the Word file containing your subjective data set on the SOAP note template into Canvas.
NU610 Unit 1 Case Study
A 19-year-old female presents with a complaint of headaches frequently. She reports that she has had
them since she was a teenager, but they have become more debilitating recently. The episodes occur
once or twice a month and last for up to 2 days. The pain begins in the right temple or the back of the
right eye and spreads to the entire scalp over a few hours. She describes the pain as a sharp, throbbing
sensation that gradually worsens and is associated with sever nausea. Several factors aggravate the pain
including loud noises and movement. She has taken several over the counter medication like naproxen
and acetaminophen for the pain but the only thing that makes it better is going to sleep in a dark quiet
room. Reports no drug allergies but has seasonal and allergies to pet dander. A thorough history reveals
her mother suffers from migraines. Last menses 4 weeks ago, is sexually active uses condoms. Currently
a freshman in college. Denies alcohol, illicit drug and tobacco use. Last health visit was over the
Summer, up to date on health maintenance for her age. She denies fever, chills, night sweats or neck
stiffness. She denies visual changes other than photophobia. She denies chest pain, palpitations,
shortness of breath or cough. She denies abdominal pain, has some nausea with the headaches but no
vomiting. Denies numbness, tingling, weakness or changes in mood. Vital signs: temperature 98.5, BP
112/70, HR 62, RR 17, 99% RA, Ht. 68 inches, Wt. 151 lbs. Alert and oriented to self, place, time and
situation. Appears stated age with skin warm and dry. Normocephalic, PERRL, TM gray with adequate
conf of light bilaterally, no tenderness over sinuses. Mucous membranes pink and dry. No palpable
masses, adenopathy or thyroid enlargement. Regular heart rate and rhythm without murmurs. No
edema. Lungs clear bilaterally, no use of accessory muscles. Soft, non-tender, non-distended abdomen
with normoactive bowel sounds. Normal visual acuity using Snellen chart 20/20, face symmetrical with
symmetrical smile and puffing out cheeks. Weber and Rinne test performed with normal bone and air
conduction. Palate and uvula at rest are free of fasciculations and symmetry noted at test and when pt.
says “ah.” Positive gag reflex. Shrug shoulders spontaneously and against resistance, hypoglossal nerve
intact. Muscle tone inspected, palpated without atrophy and strength 5/5. Bicep, patellar and Achilles
reflexes 2+ bilaterally with negative Babinski. Able to distinguish light and deep touch. Able to
complete heel to shin, gait steady.
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
S: SUBJECTIVE DATA
CC: What are they being seen for? This is the reason that the patient sought
care, stated in their own words/words of their caregiver, or paraphrased.
HPI: Use the “OLDCART” approach for collecting data and documenting
findings. [O=onset, L=location, D=duration, C=characteristics,
A=associated/aggravating factors, R=relieving factors, T=treatment,
S=summary]
PMH: This should include past illness/diagnosis, conditions, traumas,
hospitalizations, and surgical history. Include dates if possible.
ALLERGIES State the offending medication/food and the reactions.
MEDICATIONS Names, dosages, and routes of administration along with indication of
use.
SH Related to the problem, educational level/literacy, smoking, alcohol,
drugs, HIV risk, sexually active, caffeine, work and other stressors.
Cultural and spiritual beliefs that impact health and illness. Financial
resources.
FH Use terms like maternal, paternal, and the diseases along with the ages
they were deceased or diagnosed if known.
HEALTH
PROMOTION &
MAINTENANCE
Required for all SOAP notes: Immunizations, exercise, diet, etc.
Remember to use the United States Clinical Preventative Services Task
Force (USPSTF) for age-appropriate indicators. This should reflect what
the patient is presently doing regarding the guidelines. Other wellness
visits including but not limited to dental and eye exams.
Constitutional
Head
Eyes
Ears, Nose, Mouth, Throat
Neck
Cardiovascular/Peripheral
Vascular
Respiratory
Breast
ROS
(put N/A in sections
not completed day of
exam)
Gastrointestinal
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
Genitourinary
Musculoskeletal
Integumentary
Neurological
Psychiatric (screening tools: Ex:
PHQ-9, MMSE, GAD-7)
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Other
O: OBJECTIVE DATA
HR: RR: BP: Temp:
SpO2%: Ht: Wt: BMI:
VITALS:
Age: LMP: PAIN:
General Appearance
Head
Eyes
ENT, Mouth
Neck
Cardiovascular/Peripheral Vascular
Respiratory
Breast
Gastrointestinal
Genitourinary Male
• External Exam
• Internal Exam
Genitourinary Female
• External Exam
• Internal Exam
Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
PHYSICAL
EXAM
(Pertinent data
related to
presenting
problem or
visit type. Put
N/A in sections
not completed
day of exam)
Hematologic/Lymphatic
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
Allergic/Immunologic
Other
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS ICD-10 CODES
1.
2.
PRIORITIZE
DIAGNOSIS
3.
VISIT CODES CPT BILLING CODES
POC TESTINGDIAGNOSTICS
TESTS REVIEWED
P: PLAN
ACTIONS 1. Diagnosis:
Diagnostics Order: labs, diagnostics testing (tests that you planned
for/ordered during the encounter that you plan to review/evaluate
relative to your work up for the patient’s chief complaint.)
Therapeutic: changes in meds, skin care, counseling, include full
prescribing information for any pharmacologic interventions
including quantity and number of refills for any new or refilled
medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no
refills)
Education: information clients need in order to address their health
problems. Include follow-up care. Anticipatory guidance and
counseling.
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
Consultation/Collaboration: referrals or consult while in clinic with
another provider. If no referral made was there a possible referral
you could make and why? Advance care planning.
2. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
3. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
PREVENTITIVE
(Used for
comprehensive exams)
Enter Guidance, Health Promotion, and/or Disease Prevention for
patient, family, and/or caregiver.
FOLLOW UP
