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Soap Note Week 1 Sep7

Pt is a 45-year-old male presenting with neck pain and headaches for 6 months and 10 years respectively. Exam found tenderness in sub-occipital muscles and reduced vision. Assessment includes cervicogenic headache from poor posture and eye strain, as well as hypertension headache from poor posture and eye strain. Plan is to treat neck pain with chiropractic adjustments and modalities 3x/week for 2 weeks, refer to ophthalmologist, and instruct on self care.

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1K views3 pages

Soap Note Week 1 Sep7

Pt is a 45-year-old male presenting with neck pain and headaches for 6 months and 10 years respectively. Exam found tenderness in sub-occipital muscles and reduced vision. Assessment includes cervicogenic headache from poor posture and eye strain, as well as hypertension headache from poor posture and eye strain. Plan is to treat neck pain with chiropractic adjustments and modalities 3x/week for 2 weeks, refer to ophthalmologist, and instruct on self care.

Uploaded by

dondavis77
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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  • Past Medical History: Presents the patient's past medical conditions including hypertension and medication usage.
  • Subjective Information: Details the patient's personal description and subjective account of their headache and neck pain symptoms.
  • Review of Symptoms: Explores the symptoms related to various body systems including ENT, cardiovascular, and more with reported findings.
  • Assessment: Identifies potential diagnoses based on symptoms and medical examination, including cervicogenic headache.
  • Social and Objective Observations: Combines observations on the patient's social history and objective medical exam findings, including vital signs and physical exam results.
  • Plan: Outlines the treatment and management plan including physical therapy and patient education strategies.

Donald Davis

9/10/17

Subjective

Pt is a 45-year-old white male presenting today with neck pain and typical headache. “My neck hurts
right at the base of my skull. It gets worse at the end of the day and toward the end of the week.” Pt
also reports that he has had the neck pain for the past 6 months with an insidious onset. Pt reports that
his pain in his neck is 2-3/10 at the worst. Pt reports that the pain is equal on both sides of his neck. Pt
reports that his neck is achy and sore when it is hurting. Pt also reports that he gets headaches above is
eyes that radiates to the top of his head. Pt reports that he has been getting this type of headache for
about 10 years. Pt reports that it is worse at the end of the day and he does not have one in the
morning. Pt denies any prodromal symptoms. Pt reports that pain is 3-4/10 at worst. Pt reports that he
has significant eye strain at the end of the day along with his headache. Pt denies seeing an eye doctor
for many years.

Review of Systems

Constitutional Symptoms- No known symptoms

Eyes- Pt does have eye strain and headache

ENT- No known symptoms

Cardiovascular- Pt has hypertension diagnosed 2 years ago controlled with Lisinipril

Respiratory- No known symptoms

GI- No known symptoms

GU- No known symptoms

MSK- Pt has pain from the occiput to top of the thoracic spine.

Integumentary- No known symptoms

Neurological- Pt does have headaches at his eyes and radiating toward the top of his head.

Endocrine- No known symptoms

Hematologic/Lymphatic- No known symptoms

Allergic/Immunologic- No known symptoms

Past Medical Hx

Hypertension diagnosed 2yrs ago. Controlled with Lisinipril (unknown dosage)

OTC- Advil 2/200 mg 2-3 for pain at its worst.

Nutrition
Typical American diet

4/5 diet cokes a day

Family History

Mother has hx of migraines. No other significant hx

Father also has hx of hypertension

Social Hx

Pt is employed at Maryville University in the Registrars office for the past 20 years.

Pt is a non smoker and drinker.

Objective

Vitals – BP Right arm 125/82

HR- 79

RR- 12

Palpation- Pt had some tenderness in sub-occipital muscles bilaterally. Pt denied any further tenderness
in neck, above eyes, or head.

DTR- 1+ Bicep, triceps, and bracioradialis

MMT- 5/5 for UE

Rosenbalm eye exam- 20/50 Left eye

20/40 Right eye

Cardinal Gaze- normal movement

Visual field check- Pt good peripheral visual fields

Eye exam with Coaxial- Positive red reflex both eyes

Pan optic- normal eye structures

O’Donahue’s Maneuver- Active- Pain with cervical rotation and bilateral lateral bending at end ranges

Passive- Pain with cervical rotation and bilateral lateral bending at end ranges

Resisted- Pain with cervical rotation and bilateral lateral bending at end ranges

Assessment
1. Cervicogenic headache, poor posture, overuse or eye strain
2. Hypertension headache, poor posture, overuse or eye strain
3. Poor posture, tension headache, and eye strain

Plan

Treat cervical neck pain with adjustment, soft tissue mobilization, and electrical stimulation. Instruct
patient on HEP and self-care. Instruct patient on workplace ergonomics. 3x a week for 2 weeks as trial of
care. Refer patient to ophthalmologist for eye strain.

Donald Davis 9/10/17 Subjective Pt is a 45-year-old white male presenting today with neck pain and typical headache. “My n
Typical American diet 4/5 diet cokes a day Family History Mother has hx of migraines. No other significant hx Father also
1. Cervicogenic headache, poor posture, overuse or eye strain 2. Hypertension headache, poor posture, overuse or eye strai

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