Headache H&P

Instructions: Write a SOAP NOTE inclusive of a history, focused physical exam, assessment
(summary/differentials), and plan (order labs/imaging, plan for each problem). See the SOAP Note
101 document for samples and further explanation (Sample focused write-up attached to end of this
document). Remember, the summary below is merely a brief description of the patient’s complaint.
Utilize the details from class and from your knowledge of the neuro system to expand to create an
H&P that fits your diagnoses.
_____________________________________________________________________________________

Chief Complaint: “I have a terrible headache.”

SUBJECTIVE:

Lesley is a 35-year-old woman with a 10-year history of migraines. The frequency of her migraines has
increased from one to two–three per month, and they seem to be triggered by sleep deprivation and stress.
The migraines include visual auras which precede the headache with nausea but no vomiting during the
attacks. Today, Lesley presents with a 24-hour history of unilateral severe throbbing headache which is
associated with photophobia, nausea and vomiting (three times in 24 hours). Lesley’s initial self-
management was aspirin 325 mg and metoclopramide 10 mg orally which usually helps, however, she has
had no symptom relief this time around. Lesley has been unable to attend work or care for her children
and states that she rarely has such a severe attack.
Lesley has two children aged 2 and 4 years and no other relevant medical history.

Please develop and expand the HPI in an improved and organized format. Include significant positives
and negatives from the ROS and PMHx. DO NOT FORGET TO DISCUSS EACH SYMPTOM
SEPARATELY!

Past Medical History:

Migraines with aura x 10 years

Medications:

ASA 325mg PO prn migraines

Metoclopramide 10mg PO prn migraines

Allergies:

Family History:

As you like. If relevant – add the relevant Dx’s (hx brain tumors, AVMs, etc.). If the family history is
irrevelant, simply write “noncontributory.”
Personal/Social History: As you like. If relevant – add the relevant history (Admits to drinking, smoking,
drug use, caffeine use, etc). If the personal/social hx is irrevelant, simply write “noncontributory.”

- - - - - - THERE IS NO ROS SECTION - - - - - -

Make sure all your pertinents are in the HPI.

OBJECTIVE:

General survey: Lesley looks pale and tired, is photophobic, and is in acute painful distress. EXPAND
THIS.

Temperature 98.8F

BP 135/90mmHg

Heart Rate 100 beats per minute

Respiratory Rate 18 breaths per minute

SPO2 100% on room air

HT 5’ 6”

WT 120 lbs

Please complete a FOCUSED exam meaning only include the systems that you think are pertinent to the
patient’s complaint (like we did with the focused in-class write-ups). Ex: A pelvic exam would not be
warranted in this patient, so it does not need to be included as part of your documentation. Same goes for
a rectal exam, unless your patient is a trauma patient. Also do not forget ‘special tests’ if they are relevant
to your history.

ASSESSMENT

Summarize the patient’s positive history and physical findings in 1-2 sentences.

Differential Diagnoses: organize your differential diagnosis from the most likely to the least likely. Have
at least 3 differentials and indicate why you feel those differentials fit.

1.

2.

3.
PLAN

Make a plan for each of the problems (acute and chronic)

1. Acute Headache:

a. Order any labs/imaging - select all the appropriate lab tests that will capture likely
findings for all your differentials. Next to each order, indicate why you’ve chosen that
test (i.e. what will it help rule out from your differentials?)

b. Order STAT meds to help with her above symptoms (headache, nausea, vomiting, etc)

c. Referrals, if needed at this time

2. Chronic History of Migraines:

a. Any follow-ups? Address her current meds? What can we do about her chronic
migraines?

3. Patient education:

a. Address anything that you think will help her condition overall

4. Follow-up:

a. General follow-up and with whom (PCP, Neuro, ortho, etc)

LAST ONE - HAVE FUN!