Access over 20 million homework & study documents

Comprehensive Soap Template

Content type
User Generated
Subject
Health & Medical
School
Walden University
Type
Homework
Rating
Showing Page:
1/7
Comprehensive SOAP Template
Patient Initials: A-K Age: 20 years Gender: Male
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): The patient complaints about headaches that diffuses all over the
head. Intermittent headaches affect his head in the parts above his eyes. The pain comes
in bits and fades away interchangeably. The patient also claims that the pain begins on
the side above the eyes and develops through the nose, cheekbones, and the jaws. He has
been having the episodic headaches for over a week now.
History of Present Illness (HPI): The 20-year-old A-K male patient can be suffering
from a variety of symptoms that causes intermittent headaches. For instance, the
intermittent headaches can be caused by chronic migraine, chronic tension-type migraine,
new daily persistent migraine, and hemicranias continua. Also, the patient can be
suffering from cluster headaches, rebound headaches, and exercises-bound headaches.
Having vigorous exercises and medication overuse can cause intermittent headaches.
1. Location secondary headaches, sinuses headaches, facial pain, cranial neuralgias,
cluster headaches, migraine headaches, and traumatic headaches.
2. Quality The pain begins on the upper side of the eyes but develops to the nose,
jaws, and the cheekbone areas.

Sign up to view the full document!

lock_open Sign Up
Showing Page:
2/7
3. Quantity or severity Daily and episodic headaches that affects the entire head
leading to migraine.
4. Timing, including onset, duration, and frequency Headache pain stays for a
minimum of five to ten minutes all over the mentioned parts of the head. Mostly, the
patient claims that he gets the episodic migraines in the morning and when the sun is
hot.
5. Setting in which it occurs The headaches begins on the upper side of the eyes and
sounds like a heartbeat in the head causing pain. The pain further develops to the
other parts of the eyes, cheekbones, and jaws.
6. Factors that have aggravated or relieved the symptom Severe and episodic
headaches can be caused by inflammation or problems within the blood vessels,
infections, meningitis, intracranial pressure, brain tumor, and traumatic brain injury.
The pain can be relieved by avoidance of medication overuse, getting enough sleep,
reduce caffeine intake, avoid stress, and prevent headache triggers.
7. Associated manifestations Severe pain across the eyes, nasal stuffiness, and runny
nostrils. Intermittent headaches strike quickly without a warning.
Medications: Acetaminophen anti-inflammatory drugs 4gms daily
Nonsteroidal anti-inflammatory drugs less than 1000 mg daily
` Triptan drugs for severe migraines 200 mg per day
Dihydroegortamine and antimetics for mild migraines 250 mgs per day

Sign up to view the full document!

lock_open Sign Up
Showing Page:
3/7

Sign up to view the full document!

lock_open Sign Up
End of Preview - Want to read all 7 pages?
Access Now
Unformatted Attachment Preview
Comprehensive SOAP Template Patient Initials: A-K Age: 20 years Gender: Male SUBJECTIVE DATA: Include what the patient tells you, but organize the information. Chief Complaint (CC): The patient complaints about headaches that diffuses all over the head. Intermittent headaches affect his head in the parts above his eyes. The pain comes in bits and fades away interchangeably. The patient also claims that the pain begins on the side above the eyes and develops through the nose, cheekbones, and the jaws. He has been having the episodic headaches for over a week now. History of Present Illness (HPI): The 20-year-old A-K male patient can be suffering from a variety of symptoms that causes intermittent headaches. For instance, the intermittent headaches can be caused by chronic migraine, chronic tension-type migraine, new daily persistent migraine, and hemicranias continua. Also, the patient can be suffering from cluster headaches, rebound headaches, and exercises-bound headaches. Having vigorous exercises and medication overuse can cause intermittent headaches. 1. Location – secondary headaches, sinuses headaches, facial pain, cranial neuralgias, cluster headaches, migraine headaches, and traumatic headaches. 2. Quality – The pain begins on the upper side of the eyes but develops to the nose, jaws, and the cheekbone areas. 3. Quantity or severity – Daily and episodic headaches that affects the entire head leading to migraine. 4. Timing, including onset, duration, and ...
Purchase document to see full attachment
User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.

Anonymous
Really helpful material, saved me a great deal of time.

Studypool
4.7
Trustpilot
4.5
Sitejabber
4.4