Question

Patient Name: Jennifer Markus                                                                                                                                   MR#: 45879

Attending Physician: Katrina McKenzie, M.D.

Consulting Physician: Erik Anderson, M.D.                                                                                                            Date: 12/4/11

Subjective: 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 one half 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.

Objective: 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/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.

Assessment: Patient is a 33 yo female with symptoms and physical exam consistent with migraine headache.

Plan: 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.

Prevention: 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

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.

Answer 1

• SOAP note is one of the type of process adopted by pharmacist or any other health care member to provide pharmaceutical care as a part of Pharmacist's Workup of Drug Therapy (PWDT).
• Pharmacist's Workup of Drug Therapy (PWDT) is an essential component of pharmaceutical care plan and contains the thought processes necessary for pharmaceutical care.
• PWDT can be provided in the form of chart notation and two standard formats being used for this process:

(i) FARM note: Findings, Assessment, Recommendations, and Monitoring

(ii) SOAP note: Subjective, Objective, Assessment, and Plan

• SOAP note is being used to carried out the process of PWDT using patients detailed information collected all together with respect to different types of informations such as patient's demography, past medical or medication history, social history, occupational status, drug allergy, adverse drug reaction history, current chief complaints, clinical examination data, laboratory data, diagnosis, current treatment plan, additional therapy, recommendations etc.
• Based on all information collected in routine daily process at patient's bed-side, SOAP note is being created as a part of pharmaceutical care plan. Subjective information includes patient's demographics, past medical history, social history, chief complaints and clinical sign and symptoms noted by physician or doctor. Objective information includes basic clinical examination and laboratory data information. Assessment is being generated based on subjective and objective data in the form of provisional or final diagnosis. Plan inculdes current therapeutical management based on pharmacological as well as non-pharmacological approach along with recommendations, and discharge summary.