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CASESTUDY FOR CHAPTER 10
SOAP NOTE
Patient Name: Jennifer Markus MR#: 45879
Attending Physician: Katrina McKenzie, M.D.
Consulting Physician: Erik Anderson, M.D. Date: 12/4/15
S: Mrs. Markus is a 33-year-old woman with a PMH [past medical history] significant for depression, asthma, hiatal
hernia, and migraine headaches. She presents complaining of waking with a pulsing headache on the left side of her
head, with 1 day of prior increased sensitivity to light and to noises, as well as nausea, no emesis. The patient notes
that work has been increasingly stressful over the past couple weeks and she’s had trouble sleeping. She took two
tablets of ibuprofen last night in the hopes of avoiding a migraine, with minimal relief. She is currently taking
sertraline for her depression.
She denies any history of seizure, cluster headaches, or tension headaches. She does smoke approximately half a pack
of cigarettes daily. She notes that she’s been getting these headaches more frequently, as in two to three times per
month. She would like something to decrease the duration of the headache, as well as some suggestions for prevention
of future headaches.
O: VS: BP 134/80, HR 76, Temp 98.4, wt 155. Physical Exam. General: The patient is sitting with her eyes partially
covered by her hands, otherwise, no acute distress. HEENT: Normocephalic/atraumatic, conjunctivae noninjected,
pupils equal and round, reactive to light and accommodation (PERRLA), ears with normal cone of light reflex, nose
with clear discharge, throat nonerythematous. Neck: No lymphadenopathy, thyroid smooth and symmetric, no
nodularity palpated. Lungs: Clear to auscultation bilaterally. Heart: Regular rate and rhythm, no murmurs, grunts, or
rubs. Abdomen: Soft, nontender, nondistended, no abdominal bruits. Extremities: Warm and well perfused at distal
extremities, no edema bilaterally. Musculoskeletal (MSK): Strength of upper and lower extremities equal and 5/5, no
loss of sensation at extremities, normal patellar reflexes bilaterally.
A: Patient is a 33 yo female with symptoms and physical exam consistent with migraine headache.
P: Migraine Headache Treatment. Begin the patient on a combination treatment of sumitriptan 85 mg and naproxen 500
mg, daily, for the duration of the headache.
Continue with the sertraline, as it can have protective effects. Begin a smoking cessation regimen, because smoking
can worsen headaches. Recommend some manner of stress-reduction practice, whether it be regular exercise,
meditation practice, or relaxation practice.
Follow-up in 3 weeks to evaluate progress and number of headaches. At that time, will reevaluate with the possibility
of adding a beta-blocker or calcium channel blocker. Patient was advised that if this headache worsens or fails to
improve in the next 24–48 hours, she should call the clinic.
Erik Anderson, M.D.
Discussion Questions
1. This patient has migraine headaches. How do these differ from cluster headaches?
2. The format of this note is a SOAP note. Using an online search or other research method, describe what a SOAP
note is and how it’s used. What alternative formats are there for medical charting?
3. Why did the doctor ask whether Ms. Markus had a history of seizures?
4. Dr. Anderson suggests that the patient continue with sertraline, which she is taking to counteract the effects of
depression. What is the definition of depression? How is it diagnosed? What are the different types of
depression?