soap note 1

1

Clinical Encounter

INSTRUCTIONS TO PATIENT

Patient Demographics
Female, age early 20s, ethnicity of your choice
Occupation: Student
Marital Status/Family: Single
Living Arrangement/City: Lives with 2 roommates in downtown Ann Arbor

Opening Statement
“I’m here because “My headaches are getting worse.”

2nd Open-ended Response:
“My headaches have never been this bad before.”

Patient Situation and Concerns
You present with complaint of worsening headaches. The headaches began as a sensation of sinus
pressure that was unresponsive to antibiotics about three months ago. Your headaches don’t usually
present as sinus pressure anymore but are usually located on the sides of your head by your temples
and occasionally in the forehead or back of your head (occipital region). You deny experiencing visual
disturbances with your headaches. The headache does go away, but it comes back, and you have had
about 5-6 a month for the past few months, with each lasting about 3-5 days. The headaches are
triggered by alcohol consumption and emotional stress. You generally work through the pain by wearing
sunglasses on bright days, utilizing ear protection, and minimizing movement.

You were started on topiramate (Topamax) about two months ago, which reduced the frequency and
severity of your headaches slightly. You take about 2 to 4 butalbital/aspirin/caffeine tablets (Fiorinal)
daily, which only marginally helps with your pain. You continue to take topiramate twice daily. Currently,
at the time of your appointment your pain is a 6/10, and the headache is presenting as a constant,
throbbing pain located in the temporal area bilaterally. You recently took 2 Fiorinal tablets as well as
your scheduled topiramate before seeking care. You deny radiation of the pain.

Characteristics of the Condition: “My headaches are getting worse”
Onset: 3 months ago; current headache this morning
Location: sides of your head by your temples and occasionally in the forehead or back of your head;
today located in the temporal area bilaterally
Quality: throbbing pain
Severity: 6/10 – constant
Timing: triggered by alcohol consumption and emotional stress
Provoked by: triggered by alcohol consumption and emotional stress
Relieved by: wearing sunglasses on bright days, utilizing ear protection, and minimizing movement;
butalbital/aspirin/caffeine tablets (Fiorinal) daily 2-4 tabs, which only marginally helps with your pain.
You continue to take topiramate twice daily.

2

Patient’s understanding and beliefs: You are not sure what is causing the problem.
Effect on patient’s life: Symptoms are uncomfortable.
Associated symptoms: Nausea

Patient Affect/Behavior
You appear somewhat anxious, uncomfortable, grimacing, covering your eyes.

CURRENT MEDICAL HISTORY:

Medications (Meds)

● Insulin pump
● butalbital/aspirin/caffeine tablets (Fiorinal) 2-4 daily
● topiramate 25mg BID

Allergies

● NKDA

Past Medical History
● Type 1 diabetes

Past Surgical History

● None

Hospitalizations

● None

Family History
● Both parents are living, mother is a Type 1 diabetic as well, aged 55 yo. Father is alive and

healthy, aged 58yo.
● Paternal grandmother deceased age 70 brain aneurysm
● One sister, 29 yo, healthy.

Social History

● You are about to graduate college at UM with your Bachelor’s in Business
● Single
● Live with a few friends in a house near campus
● Smokes socially on weekends when out. Consumes 2 or 3 beers daily (up to 8 depending on the

situation) on the weekends on average.
● No drug use.
● Sexually active, and headaches are occasionally triggered after climax with sexual encounters

Health Maintenance: Last physical about 1-2 years ago. Up to date on flu shot, got at University Health
Services. Plays soccer for school rec team and runs regularly. Tries to eat healthy but eats what is
available and easy to access. Drinks “a lot” of water every day.

Menstrual History (for female volunteers):
Your first period was at age 11 with periods becoming regular by age 13. Occur monthly. LMP- about 2
weeks ago. You use condoms for contraception. Occasionally headaches are triggered by menses.

3

Review of Systems (ROS):

Constitutional Overall health?
Fever? Fatigue?
Difficulty sleeping?

I consider myself to be very healthy. No recent weight loss or
fatigue, fever, and problems sleeping

HEENT Any recent head colds? No head colds, no sore throat, no ear pain, eye pain, recent
infections.

Cardiac Chest pain? No chest pain, no flutters in your chest, no history of heart
problems.

Respiratory Any SOB? Cough? No problems with feeling short of breath or wheezing

GI Nausea/Vomiting?
Tolerating diet?

+ nausea with headaches, no vomiting. Don’t want to eat
when feeling queasy.

Neuro Weakness, lightheaded,
dizziness, vision changes,
hearing changes?

No problems with weakness, feeling lightheaded or dizzy, no
visual or auditory changes

Mental
Health

Mood? Concentration? Sad?
Stress?

No change in moods; no problems concentrating on daily
tasks; not feeling sad; are under stress with final exams
coming up and looming graduation – need to find a real job,
and take on more adult responsibilities

Vital Signs: Temperature: 99 F, Pulse: 89 bpm, BP: 143/82, Respiratory Rate: 16, SpO2 99% RA

During the encounter you should appear as below:

General: No apparent distress but appears to be in pain; Appropriate hygiene and grooming, appropriate
affect, cognition, and thought process.

Original work, Need a SOAP Note with the information provided on the attached sheet