SOAP Note #1 Health History-

Mr. Bruce Roberts is a 41 YO Caucasian Male working in a warehouse who presents for an
annual check-up in the outpt clinic.

I have been experiencing headaches for about two weeks.

Chief Complaint
Pt reports an onset of two weeks ago and with headache in the evenings. Headache is mostly
in the “rear of my head”. No reported radiation with a severity of 7/10 that sometimes keeps the
pt awake. Pt reports experiencing the headache nightly with minor relief from Motrin 600mg in
History of Present approximately 2 hours. However pt reports pain remains until waking in the morning. Pt reports
Illness a loss of approx. 2hrs of sleep D/T pain and discomfort.
The pt also reports that the discomfort is causing irritability, mild anxiety, and straining his
relationship and ability to work.

Pt reports no major illness or injury throughout life. Vaccinations are current and pt had
chicken pox without complications at age 6, “my mom took me to a chicken pox party”. No
additional exposure to childhood illness’.

Pt reports no Hx of Adult illness including CAD, Cancer, diabetes, HTN.

Pt appears to be approximately 20 lbs overweight with a BMI of 35. Pt reports no exposure to
STDs including AIDS/HIV, and reports no severe dangerous sexual behavior.
Past Med Hx
Pt considers himself in “good health”.

Pt reports a single Emergency Hospital visit from an MVA approx. 10 years ago resulting in a
broken L hand with no squella.

Tonsil removal at age 12, wisdom teeth removal at age 20.

Past Surg Hx
Both parents still alive and married. Maternal Hx of Breast CA, Paternal Hx of Colon CA, HTN,
Family Hx DM.
Pt reports 1 biological sister who passed at age 50 from untreated Breast CA.

Pt was born in Sacramento CA and has 1 older living sister and 1 younger brother. As noted 1
older sister passed away from Breast CA approx. 2 years ago. Pt was reared in a loving home
with an unremarkable upbringing. Pt achieved some college with no degree. Pt spent 4 years in
the Army as a motor vehicle operator and denies any PTSD or combat exposure.

Pt considers himself psychologically healthy and reports appropriate coping skills to manage
stress as: “exercise, reading, hanging out with friends, and photography”.

Social Hx Pt reports owning his own home and lives with his girlfriend of 4 years with no children.
Pt is sexually active in a monogamous relationship and reports a “healthy sexual relationship”.
Pt reports no intent to have children and his partner is Rx oral contraceptives. Pt’s home is a
mid-80’s single family residence and pt reports checking smoke alarms bi-annually. Pt reports
owning “a few” firearms and reports that they are locked at all times. No emotional health
concerns at this time R/T firearm ownership or safety.

Pt’s reports his career is stable and affords him a “comfortable living”. Although this job is not
likely the his long term career goal, “it will do for now”.
 Pt reports a desire to continue with college to pursue a career in photography or digital art. Pt is
exposed to some mild chemicals such as cleaning supplies and diesel fuel, and his hobby of
photography also exposes him to specific chemicals.

Pt has access to healthcare as a work benefit as well as VA healthcare R/T military service. Pt
reports having access to medical/Dental/mental health/vision coverage.

Diet: pt reports a moderate diet of mixed foods with 2-3 servings of Fruit/Vegetables daily. Pt
eats meat daily but recognized the need to balance diet. (Refer to BMI and current weight
Social Hx Cont… imabalance). Pt consumes 6 cups of coffee daily but denies any other caffeinated sources.

Pt reports moderate exercise approx. 3x/week and expresses a desire to increase exercise with
a goal of running a 5K within the next 6 months. Pt states that he used to run a lot in the Army
and would like to “get back in shape”. Pt has no limitations at this time that would prevent such
activity.
Pt reports normal sleep patterns of 6-7 hours nightly except for the past 2-3 weeks.
Pt reports no concerns going to or staying asleep and reports feeling rested upon waking.

Motrin for generalized pain and headaches, no RX.

Medications
Allergies: Self-reported “shellfish” allergy that presents as “throat tightness and itching”. Pt
takes Diphenhydramine 50mg to relieve symptoms and has never been hospitalized as a result
Allergies of exposure. Pt reports approx. 30 min between exposure and onset of itching and throat
tightness. Pt has no current Rx for Epi-pen. Pt has no medication or latex allergies.

Pt smokes 1 pack of cigarettes weekly and consumes ETOH approx. “3 beers daily on
weekends”. No illicit drug use reported but has a Hx of THC “approx. 20x during high school”.
Pt is not interested in smoking cessation at this time however education was provided in relation
Tobacco, Alcohol, to the pt’s exercise goals and encouraged to mediate smoking as part of his personal goals, and
Drugs pt agrees to report smoking cessation success’ upon next encounter.
Pt further agrees to monitor ETOH intake as part of his fitness tracking for the purpose of
reducing excess weight.

General / Constitutional- pt reports a weight gain of 20 lbs within the last 12 months potentially
D/T a lack of exercise, increased ETOH intake, stress with work and relationships.

Skin- no changes, pt presents w/o concerns

Eyes- no report of pain, blurring, dbl vision or spots

Ears- inspection demonstrates no abnml findings

Nose- clear, supple, no septum deviation, no reports of nose bleeds

Mouth/Throat- upon inspection; no abnml findings. Pt presents with minor non-clinical halitosis
and several fillings. No neck abnormalities, stiffness, pain or tenderness upon palpation.
ROS
Cardiovascular- no reports of chest pain / tightness. Negative Cardiac Hx. Negative edema,
negative SOB with/without exercise. Auscultation is unremarkable.

Respiratory- Clear upon auscultation and palpation/percussion. No pain or abnormalities. Pt is

clear bilateral without wheezing or stridor. No recent Cxr or need for further examination.

Gastrointestinal- Pt reports no S/S of GI distress or concern. Normal BM including timing, size,

consistency, color. Pt denies heartburn, GERD, or abnml pain. Bowel sounds present in all 4
quadrants upon auscultation.
 Genitourinary- no abnormal report or findings. Pt reports normal urination and ejaculatory
process. No STD exposure and currently in a monogamous relationship. No Hx of kidney
stones or abnormal discharge.
Pt provided education R/T testicular exam.

Breast- Family Hx of Breast CA, Pt provided education R/T self exam. Negative R/T
discharge/masses/ no pain upon palpation.

Musculoskelatal- no reports of pain, limitations of motion, weakness, or atrophy. Pt appears to

be in good muscular health with no limitations to current plan of increasing overall health through
physical activity.

Neurologic- Pt reports Chief Complaint as “Headaches”.

Focused exam does not reveal any physical cause of pain. Negative for mentation changes,
lightheadedness, syncopy, sensory disturbances, convulsions, concerns with coordination,
tremor.
ROS Cont… Pt reports an increase in Caffeine intake and reduction in water consumption. Additionally, Pt
reports increased stress with relationships and work. Recommendations provided for stress
reduction, dietary increase in water, reduction in overall caffeine intake over the next few weeks,
reduction in smoking over the next few months with nicotine replacement therapy starting upon
request.

Mental/Psychiatric- Pt reports increased anxiety R/T work and partner relationship. Pt reports
an increased expectation for long term commitment over the past 6 months that may have led to
increased stress. Pt denies thoughts of self-harm of depression.

Lymphatic- no S/S of lymph system impact upon inspection/palpation. No reports of concerns

Hematologic- No reports of abnormal bleeding, no Hx of transfusions.

Endocrine- Recent change in weight but no S/S of medical etiology. Skin, hair, all normal. No
reports of excessive thirst or urination.
Pt is a 41 YO Caucasian male in good health minus a recent increase of weight of approx. 20
lbs with a CC of headaches 7/10 at night. Headache minimally relieved with 600mg Motrin.
No significant PMH or Family Hx R/T CC
Pt reports an increase in personal and professional stress that may be leading to headaches.

Vital Signs: WNL

Pt is appropriate and in overall good health upon initial health Hx and preliminary inspection.
No abnml physical findings.

Preliminary neuro eval negative and Systems fully intact and unremarkable.
Likely possibilities include overexposure to caffeine, increased social and work stress, and social
anxiety.

Summary Caffeine, tobacco, and alcohol intake within reasonable limits however reductions recommended
to further evaluate current complaint.
Stress relief activities encouraged however recommendations provided to avoid exposure to
photography chemicals until headaches are resolved.
Increase exercise to accomplish personal health goals including competing in a 5K timed run.
Recommendations for journaling both headache onset as well as activities within 2 hours of
onset. Further recommendations include increasing water intake with measurements to include
observing urine for clarity.

Further workup to include CBC, Lipid panel, smoking cessation, CMP.

Encourage remote F/U through E-Portal with preferred follow up available if no resolution of
headaches within 2-3 weeks.