Prepare a focused assessment SOAP note for Migraine headache as a primary diagnosis.
Tension Headache and Cluster Headache as differential diagnosis.
I will include a sample and the SOAP template.
Prepare and complete an Episodic/Focus Note Template Form where you will gather patient information and relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, past medical history (PMH), socioeconomic status, and cultural background. You need a HEENT(Head, Eyes, Ears, Nose, Throat) patient for the SOAP. All Physical Exams (PEâ€™s) in this course are focused, so you only need to examine the area of chief complaint and any pertinent history system (hx of GIB, IBSâ€¦ examine the abdomen, history of DM â€“ look at skin), and always, always, always do a cardiac and respiratory exam.
All assignments are considered formal in this course and require APA 7.
- Subjective: What details did the patient provide regarding her personal and medical history?
- Objective: What observations did you make during the physical assessment?
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What would you do differently in a similar patient evaluation?