Patient Name: JenniferMarkus                                                                                                                                   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 womanwith a PMH [past medical history] significant fordepression, asthma, hiatal hernia, and migraine headaches. Shepresents complaining of waking with a pulsing headache on the leftside of her head, with 1 day of prior increased sensitivity tolight and to noises, as well as nausea, no emesis. The patientnotes that work has been increasingly stressful over the pastcouple weeks and she’s had trouble sleeping. She took two tabletsof ibuprofen last night in the hopes of avoiding a migraine, withminimal relief. She is currently taking sertraline for herdepression.
She denies any history of seizure, cluster headaches, or tensionheadaches. She does smoke approximately one half pack of cigarettesdaily. She notes that she’s been getting these headaches morefrequently, as in two to three times per month. She would likesomething to decrease the duration of the headache, as well as somesuggestions for prevention of future headaches.
Objective: VS: BP 134/80, HR 76, Temp 98.4, wt155. Physical Exam. General: The patient is sitting withher eyes partially covered by her hands, otherwise, no acutedistress. HEENT: Normocephalic/atraumatic, conjunctivaenoninjected, pupils equal and round, reactive to light andaccommodation (PERRLA), ears with normal cone of light reflex, nosewith clear discharge, throat nonerythematous. Neck: Nolymphadenopathy, thyroid smooth and symmetric, no nodularitypalpated. Lungs: Clear to auscultation bilaterally. Heart: Regularrate and rhythm, no murmurs/grunts/rubs. Abdomen: Soft, nontender,nondistended, no abdominal bruits. Extremities: Warm and wellperfused at distal extremities, no edema bilaterally.Musculoskeletal (MSK): Strength of upper and lower extremitiesequal and 5/5, no loss of sensation at extremities, normal patellarreflexes bilaterally.
Assessment: Patient is a 33 yo female withsymptoms and physical exam consistent with migraine headache.
Plan: Migraine Headache Treatment.Begin the patient on a combination treatment of sumitriptan 85 mgand naproxen 500 mg, daily, for the duration of the headache.
Prevention: Continue with the sertraline, as itcan have protective effects. Begin a smoking cessation regimen,because smoking can worsen headaches. Recommend some manner ofstress-reduction practice, whether it be regular exercise,meditation practice, or relaxation practice.
Follow-up in 3 weeks to evaluate progress and number ofheadaches. At that time, will reevaluate with the possibility ofadding a beta-blocker or calcium channel blocker. Patient wasadvised that if this headache worsens or fails to improve in thenext 24–48 hours, she should call the clinic.
Erik Anderson, M.D.
Discussion Questions
2.    The format of this note is a SOAPnote. Using an online search or other research method, describewhat a SOAP note is and how it’s used.
