SOAP Note – I&C

This SOAP note was written based on a hypothetical patient prompt for Interview & Counseling.

CC: Feeling “really sleepy all day” and feels like she isn’t functioning well at work

HPI: A 36 y/o female smoker (15 pack-years) and chronic cough x4 years presents to the clinic with complaints of fatigue, visual disturbances described as “wavy lines”, and nausea. Patient has a history of migraines with aura that first began 2 years prior. She reports no headaches since beginning Amitriptyline 50mg qhs and associated prodrome symptoms resolve with use of Zolmitriptan 2.5mg. Prodrome symptoms appear to be interfering with functioning at work.

General: fatigue, no fever, no chills, no generalized weakness, no loss of appetite
Head: no headache, no vertigo, no head trauma
Eye: no blurring, no diplopia, no fatigue with use of the eyes, no scotoma, no halos, normal lacrimation, no photophobia, no pruritis, visual disturbance – wavey lines
Ear: no deafness, no pain, no discharge, no tinnitus
Nose/Sinuses: no discharge, no congestion, no epistaxis
Mouth and throat: no bleeding gyms, no sore tongue, no sore throat
Neck: no localized swelling, no stiffness/decreased ROM
Breast: no lumps, no discharge, no pain
Cardiovascular/pulmonary: no dyspnea, chronic cough, no chest pain, no orthopnea, no paroxysmal nocturnal dyspnea, no edema, no hemoptysis, no palpitations, no syncope, no wheezing, no known heart murmur
Gastrointestinal System: no change in appetite, no food intolerance, no nausea/vomiting, no dysphagia, no pyrosis, no flatulence, no eructation, no abdominal pain, no diarrhea, no jaundice, no change in bowel habits, no hemorrhoids, no constipation. Last colonoscopy in 2016 was unremarkable with no polyps
Skin, Hair Nails: no sweating, no dryness, no discolorations/abnormal pigmentations, no changes in hair distribution, no pruritis
Genitourinary – no change in urinary frequency, no nocturia, no urgency, no oliguria, no polyuria, no dysuria, normal color, no stress incontinence, no pain
Sexual History – unknown
Menstrual and Obstetrical – unknown
Nervous System – no seizures, no sensory disturbances including numbness, paresthesia, or dysesthesias, no ataxia, no loss of strength, no change in mental status, no weakness
Musculoskeletal System – no muscle/joint pain, no deformity or swelling/redness, no arthritis
Hematologic System –no anemia, no easy bruising or bleeding, no lymph node enlargement
Endocrine – no polyuria, no polydipsia, no polyphagia, no heat or cold intolerance, no goiter
Peripheral Vascular System – no intermittent claudication, no coldness or trophic changes, no varicose veins, no peripheral edema, no color change

Physical Exam:
VS: P100, R 20, BP 140/88, Temp 98.6 ͦF
Pupils are round and reactive to light, there is no pain when the light is directed at her eyes
There is no distress or avoidance of opening her eyes or moving her head
Extra ocular movements are full, no pain on extreme lateral gaze
visual acuity is unchanged from last exam (20/40 Bilaterally)
Examination of her chest reveals clear lungs and a regular heart rate and rhythm with no murmurs or gallops
Inspection of her nose shows pink mucosa, no masses or lesions, bilateral nares are clear of discharge and patient can breathe through both sides normally
Penlight exam of her throat shows no redness or exudates, palate lifts symmetrically, tongue protrudes in the midline.
The color is generally within normal limits with no cyanosis and her conjunctivae are pink.
Skin is warm, moist, and has normal turgor

Somnolence secondary to medication therapy
Migraine with aura, not intractable, without status migrainosus
R/O sleepiness from new prodrome symptoms
Smoker’s Cough
Tobacco Use Disorder

-Reduce Amitriptyline from 50 mg qhs to 25 mg qhs and continue Zolmitriptan 2.5 mg nasal spray, up to 2 doses PRN for acute headache
-Begin Zofran 4mg every 4-8 hrs PRN for nausea
-Begin Enalapril 2.5mg for HTN and titrate to response
-Order complete metabolic panel to get baseline before starting ACE-i
-Follow up in one month to monitor