Regional Write-Up and SOAP Documentation: Head, Face, and Neck

Date 10/6/2023
Student Name R.L.

Volunteer Initials R.L

Age 24
Gender Female
Reason for Visit Headache

I. Health History (subjective)

Yes or No. If yes, explain.
1. Any unusually frequent or severe
headaches
Yes, pt. complains of frequent headaches behind
their eyes, ever since patient played in an
intramural soccer game about 5 days ago. Pt.
states they feel dizzy and have blurry vision.
Headaches started a day after playing in the
soccer game.

2. Any head injury Pt. states they did play In an intramural soccer
game and knocked heads with another player
about 5 days ago.

3. Experienced any dizziness Yes, at onset of headache, pt. states they feel
dizzy and sometimes needs to lay down to help
with the dizziness.

4. Any neck pain Denies

5. Any lumps or swelling in the head or Denies

neck
6. Any surgery on the head or neck Denies, pt. has no surgical hx.

II. Physical Examination (objective)

1. Inspect and palpate the skull

General size and contour Head and neck are midline. Neck muscles are
symmetric and have an appropriate range of motion.
No enlargement of glands or pulsations.
Temporal artery
+2 and equal on both sides

Temporomandibular joint no
abnormalities when patient open
and closes their mouth. Condylar
movement is easily felt and equal
on both sides.

2. Inspect the face

Facial expression

Facial expressions are appropriate

and symmetric.

Symmetry of structure: all facial

features are symmetric. Eyes are
PERRLA

Involuntary movements: no
involuntary movements noted

Edema: no facial edema noted

Masses or lesions: no masses or

lesions noted

Color and texture of skin

3. Inspect the neck
Symmetry
Range of motion, active
Test strength of cervical muscles
Abnormal pulsations
Enlargement of thyroid
Enlargement of lymph and salivary
glands

4. Palpate the lymph nodes

 Exact location
Size and shape
Presence or absence of tenderness
Freely moveable or adherent
matted
Presence of inflammation
Texture (hard, soft, firm)
5. Palpate the trachea
Exact location
Symmetry or deviation from midline
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Based on your findings above, write SOAP documentation.

Introduction: R.L. is a 24-year-old female who comes in with a complaint of a headache and
episodes of acute confusion and reduced cognitive ability.

Subjective: Pt. complains of frequent headaches paired with dizziness and episodes of acute
confusion impairing cognitive ability, after she bumped heads with a playr during a soccer game
about 5 days ago. Pt. states she frequently feels dizzy with these headaches and experiences
intermittent episodes of confusion.

Objective: Head and neck are midline. Neck muscles have an appropriate range of motion. No
enlargement of glands and lymph nodes is appreciated. No lumps identified. Temporal arteries
are +2 and equal throughout. No issues noted with temporomandibular joint. All facial features
are symmetric with no edema, mass or lesions noted. Pupils are equal and active throughout.
Skin color and temperature are appropriate for ethnicity. The neck is symmetrical with an
appropriate range of motion noted in cervical muscles. Thyroid gland is appropriate in size and
no abnormalities noted in lymph nodes. Trachea appears to be midline and intact.

Assessment: Acute confusion and dizziness related to a minor blow to the head impairing
patient’s cognitive ability.

Plan:
Reference:
Jarvis, C. (2020). Study Guide & Laboratory Manual Physical Examination & Health Assessment,
8th ed. Elsevier.