SOAP Note Case , I uploaded an example, you can create your own case, with a person older than 21 years. Including patient name initials , date of birth and all the examples of personal and medical history provided in the example. I need all the information wrote in the example, No require references, PLEASE everything must be related because is the same case.
SOAP Note Case Study: Ms. A.T.
Patient Information:
Name: Ms. A.T.
Date of Birth: November 15, 1990
Chief Complaint:
Ms. A.T. presents with complaints of headache, fatigue, and occasional dizziness.
History of Present Illness:
Ms. A.T. reports experiencing these symptoms for the past two weeks. She describes her headache as a dull, constant pain that is typically worse in the afternoon. The fatigue has been progressively worsening, and she feels excessively tired even after a full night’s sleep. The dizziness occurs occasionally when she changes positions rapidly, such as standing up quickly.
Personal History:
Ms. A.T. is a 30-year-old female who works as a project manager for a software company. She lives a sedentary lifestyle due to the nature of her job, spending most of her time sitting in front of a computer. She denies any recent changes in her diet or exercise routine.
Medical History:
1. Migraine Headaches: Ms. A.T. has a history of occasional migraines, usually triggered by stress. The headaches are typically unilateral and associated with nausea and sensitivity to light and sound.
2. Hypothyroidism: Ms. A.T. was diagnosed with hypothyroidism at the age of 25. She takes levothyroxine daily to manage her thyroid hormone levels.
3. Seasonal Allergies: Ms. A.T. reports a history of seasonal allergies, primarily manifesting as nasal congestion, sneezing, and itchy eyes during the spring months.
4. Anxiety: Ms. A.T. has a history of anxiety, which she manages with lifestyle modifications and occasionally with relaxation techniques.
5. Family History: Ms. A.T.’s mother has a history of migraines, and her paternal grandmother had hypothyroidism.
Current Medications:
1. Levothyroxine 50 mcg, 1 tablet daily for hypothyroidism.
2. Loratadine 10 mg, 1 tablet daily as needed for seasonal allergies.
3. Alprazolam 0.5 mg, 1 tablet as needed for anxiety.
Review of Systems:
General: Fatigue
Head: Headache
Eyes: No visual changes, no eye pain, no double vision
Ears, Nose, Throat: No ear pain, no nasal congestion, no sore throat
Respiratory: No shortness of breath, no cough
Cardiovascular: No chest pain, no palpitations
Gastrointestinal: No nausea, no vomiting, no diarrhea, no abdominal pain
Genitourinary: No urinary changes, no genital discomfort
Musculoskeletal: No joint pain, no muscle weakness
Integumentary: No rashes, no abnormal pigmentation
Neurological: Dizziness with position change
Psychiatric: No depressed mood, no suicidal ideation
Physical Examination:
Vital Signs:
– Blood pressure: 120/80 mmHg
– Heart rate: 76 beats per minute
– Respiratory rate: 14 breaths per minute
– Temperature: 37.0 °C (oral)
General: Ms. A.T. appears well-nourished and in no acute distress.
Head: Normocephalic, atraumatic. No tenderness on palpation.
Eyes: Pupils equal and reactive to light. Extraocular movements intact. Fundoscopic exam reveals normal optic discs with sharp borders and no signs of papilledema.
Ears, Nose, Throat: No abnormalities on external examination. Tympanic membranes intact and pearly gray bilaterally. No nasal polyps or discharge. Oropharynx is clear.
Neck: Supple. Thyroid gland non-palpable. No cervical lymphadenopathy.
Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops. Peripheral pulses are 2+ and equal bilaterally.
Respiratory: Clear breath sounds bilaterally. No wheezes, rales, or rhonchi.
Gastrointestinal: Soft and non-tender abdomen. No organomegaly or masses palpated. Bowel sounds are normal.
Genitourinary: No abnormal findings on external examination.
Musculoskeletal: Full range of motion in all joints. No joint deformities. Muscle strength is normal.
Integumentary: No rashes or skin lesions noted.
Neurological: Oriented to person, place, and time. Normal cranial nerves. Gait is steady with normal coordination. No focal motor or sensory deficits.
Psychiatric: Pleasant and cooperative. No evidence of depressed or anxious mood.
Assessment:
1. Migraine Headaches: Ms. A.T.’s history of occasional migraines and her current headache symptoms suggest a possible exacerbation of her migraines.
2. Fatigue: The progressive fatigue reported by Ms. A.T. warrants further investigation to rule out any underlying causes.
3. Dizziness: Ms. A.T.’s occasional dizziness with positional change may be related to hypotension or orthostatic hypotension.
Plan:
1. Migraine Management: Recommend Ms. A.T. to maintain a headache diary to monitor triggers and patterns of her migraines. Discuss relaxation techniques and stress management strategies. Consider prophylactic medication if headaches significantly impact her quality of life.
2. Fatigue Evaluation: Order a comprehensive blood panel, including thyroid function tests, complete blood count, and metabolic panel, to evaluate for underlying causes of the fatigue. Instruct Ms. A.T. to maintain a regular sleep schedule, prioritize good nutrition, and engage in regular exercise.
3. Dizziness Investigation: Recommend orthostatic blood pressure measurements to evaluate for orthostatic hypotension. Advise Ms. A.T. to stay adequately hydrated and avoid sudden position changes.
Follow-Up:
Schedule a follow-up appointment in two weeks to review the results of the lab tests and monitor the patient’s symptoms. Ms. A.T. should contact the healthcare provider sooner if her symptoms worsen or new concerns arise.
This SOAP note presents a case study of Ms. A.T., a 30-year-old female who presents with headache, fatigue, and occasional dizziness. Her personal and medical history, along with the physical examination findings, aid in formulating an assessment and creating an appropriate plan for further evaluation and management.