Z.T. is a 29- year -old male with no significant past medical history. Family history includes a father with diabetes, a mother with hypertension diagnosed at age 42; and a paternal grandfather with myocardial infarction at age 52, stroke at age 60, and heart failure diagnosed at age 52. Z.T. presents to the clinic with a headache for the past 12 hours and slightly blurred vision. He appears anxious but denies pain other than his headache.
Complete a SOAP note for an intake. What additional information do you need for subjective and objective data? Next, design a treatment plan based on the information you have available; include pharmacological, non-pharmacological, patient education, referral, and follow-up.