essay
rosario08
advhealthassessmentsoapassessmentweekIIIneuro1.docx
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
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Initials: TJ |
Age: 28 |
Gender: Female |
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Height |
Weight |
BP |
HR |
RR |
Temp |
SPO2 |
Pain Rating | |
| 170 | 90 kg | 142/82 | 86 | 19 | 101.1 | 99 |
3/10 |
Medication: albuterol and Tylenol 325 mg PRN Food: NKA Environment: dust, cats |
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History of Present Illness (HPI) |
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Chief Complaint (CC) | Patient presents complaining of headache after a recent minor car accident or “ I got into a little tender a week ago and I have been getting these headaches ever since. And my neck is sire too” |
CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom |
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O nset | 2 weeks ago ( right after the accident) |
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L ocation | Head and neck |
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D uration | 1 to 2 hours ( comes and goes) |
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C haracteristics | dull ache, kind of in the crown of my head, and the back of my head, soreness in my neck feels like it goes up into my head |
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A ggravating Factors | Activity, ambulation |
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R elieving Factors | Tylenol and rest |
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T reatment | Tylenol OTC 325 Q 6 or prn |
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Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. |
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Medication (Rx, OTC, or Homeopathic) |
Dosage |
Frequency |
Length of Time Used |
Reason for Use |
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| Tylenol | 325 mg | Q6 or PRN | 2 weeks ago | Neck pain and headache | ||||
| Proventil | 90mcg | prn | Since she was 16 years old ( Dx with asthma) | Asthma | ||||
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Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed.
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Estimates 5 hospitalization for asthma Recent hospitalization to ER for wound injury in right foot No hx of surgeries Pt was vaccinated for meningitis at age of 19 years old when patient was in college Pt denied any issues of spines surgeries Pt denied any hx of neurological disorders and no family hx of neurological disorders |
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Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. |
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Pt just had a minor car accident two weeks ago Pt enjoyed reading Pt currently working and has medical insurance Pt enjoyed going out with her friends, church activities and reading Pt reported general low activity level. Pt is diabetic in noncompliance with diabetes medication Patient drink alcohol one or two drink per week or less. Pt denied smoking and pt used to smoke marihuana in the past when she was 20 or 21 years old Pt denied use of tobacco or shewing tobacco.
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Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. |
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Pt family hx of HTN, Hyperlipidemia, Asthma, and Diabetes type II and Colon Cancer.
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Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. |
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Constitutional If patient denies all symptoms for this system, check here: ☒ |
Skin If patient denies all symptoms for this system, check here: ☐ |
HEENT If patient denies all symptoms for this system, check here: ☐ |
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☐Fatigue Click or tap here to enter text. ☐Weakness Click or tap here to enter text. ☐Fever/Chills Click or tap here to enter text. ☐Weight Gain Click or tap here to enter text. ☐Weight Loss Click or tap here to enter text. ☐Trouble Sleeping Click or tap here to enter text. ☐Night Sweats Click or tap here to enter text. ☐Other: Click or tap here to enter text. |
☐Itching Click or tap here to enter text. ☐Rashes Click or tap here to enter text. ☐Nail Changes Click or tap here to enter text. ☒Skin Color Changes face and neck ☐Other: Click or tap here to enter text.
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☐Diplopia Click or tap here to enter text. ☐Eye Pain Click or tap here to enter text. ☐Eye redness Click or tap here to enter text. ☒Vision changes blurred vision ☐Photophobia Click or tap here to enter text. ☐Eye discharge Click or tap here to enter text.
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☐Earache Click or tap here to enter text. ☐Tinnitus Click or tap here to enter text. ☐Epistaxis Click or tap here to enter text. ☐Vertigo Click or tap here to enter text. ☐Hearing Changes Click or tap here to enter text.
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☐Hoarseness Click or tap here to enter text. ☐Oral Ulcers Click or tap here to enter text. ☐Sore Throat Click or tap here to enter text. ☐Congestion Click or tap here to enter text. ☐Rhinorrhea Click or tap here to enter text. ☒Other: Headache and neck pain
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Respiratory If patient denies all symptoms for this system, check here: ☒ |
Neuro If patient denies all symptoms for this system, check here: ☐ |
Cardiac and Peripheral Vascular If patient denies all symptoms for this system, check here: ☒ |
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☐Cough Click or tap here to enter text. ☐Hemoptysis Click or tap here to enter text. ☐Dyspnea Click or tap here to enter text. ☐Wheezing Click or tap here to enter text. ☐Pain on Inspiration Click or tap here to enter text. ☐Sputum Production Choose an item. Choose an item. Choose an item. ☐Other: Click or tap here to enter text.
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☐Syncope or Lightheadedness Click or tap here to enter text. ☒Headache Click or tap here to enter text. ☐Numbness Click or tap here to enter text. ☐Tingling Click or tap here to enter text. ☐Sensation Changes Choose an item. ☐Speech Deficits Click or tap here to enter text. ☐Other: Click or tap here to enter text.
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☐Chest pain Click or tap here to enter text. ☐SOB Click or tap here to enter text. ☐Exercise Intolerance Click or tap here to enter text. ☐Orthopnea Click or tap here to enter text. ☐Edema Click or tap here to enter text. ☐Murmurs Click or tap here to enter text.
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☐Palpitations Click or tap here to enter text. ☐Faintness Click or tap here to enter text. ☐Claudications Click or tap here to enter text. ☐PND Click or tap here to enter text. ☐Other: Click or tap here to enter text.
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MSK If patient denies all symptoms for this system, check here: ☐
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GI If patient denies all symptoms for this system, check here: ☒ |
GU If patient denies all symptoms for this system, check here: ☒ |
PSYCH If patient denies all symptoms for this system, check here: ☒ |
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☒Pain headache and neck pain ☒Stiffness soreness and stiffness in neck ☐Crepitus Click or tap here to enter text. ☐Swelling Click or tap here to enter text. ☐Limited ROM Choose an item. ☐Redness Click or tap here to enter text. ☐Misalignment Click or tap here to enter text. ☐Other: Click or tap here to enter text.
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☐Nausea/Vomiting Click or tap here to enter text. ☐Dysphasia Click or tap here to enter text. ☐Diarrhea Click or tap here to enter text. ☐Appetite Change Click or tap here to enter text. ☐Heartburn Click or tap here to enter text. ☐Blood in Stool Click or tap here to enter text. ☐Abdominal Pain Click or tap here to enter text. ☐Excessive Flatus Click or tap here to enter text. ☐Food Intolerance Click or tap here to enter text. ☐Rectal Bleeding Click or tap here to enter text. ☐Other:
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☐Urgency Click or tap here to enter text. ☐Dysuria Click or tap here to enter text. ☐Burning Click or tap here to enter text. ☐Hematuria Click or tap here to enter text. ☐Polyuria Click or tap here to enter text. ☐Nocturia Click or tap here to enter text. ☐Incontinence Click or tap here to enter text. ☐Other: Click or tap here to enter text.
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☐Stress Click or tap here to enter text. ☐Anxiety Click or tap here to enter text. ☐Depression Click or tap here to enter text. ☐Suicidal/Homicidal Ideation Click or tap here to enter text. ☐Memory Deficits Click or tap here to enter text. ☐Mood Changes Click or tap here to enter text. ☐Trouble Concentrating Click or tap here to enter text. ☐Other: Click or tap here to enter text. |
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GYN If patient denies all symptoms for this system, check here: ☒ |
Hematology/Lymphatics If patient denies all symptoms for this system, check here: ☒ |
Endocrine If patient denies all symptoms for this system, check here: ☐ |
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☐Rash Click or tap here to enter text. ☐Discharge Click or tap here to enter text. ☐Itching Click or tap here to enter text. ☐Irregular Menses Click or tap here to enter text. ☐Dysmenorrhea Click or tap here to enter text. ☐Foul Odor Click or tap here to enter text. ☐Amenorrhea Click or tap here to enter text. ☐LMP: Click or tap here to enter text. ☐Contraception Click or tap here to enter text.
☐Other:Click or tap here to enter text.
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☐Anemia Click or tap here to enter text. ☐ Easy bruising/bleeding Click or tap here to enter text. ☐ Past Transfusions Click or tap here to enter text. ☐ Enlarged/Tender lymph node(s) Click or tap here to enter text. ☐ Blood or lymph disorder Click or tap here to enter text. ☐ Other Click or tap here to enter text.
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☐ Abnormal growth Click or tap here to enter text. ☐ Increased appetite Click or tap here to enter text. ☐ Increased thirst Click or tap here to enter text. ☐ Thyroid disorder Click or tap here to enter text. ☐ Heat/cold intolerance Click or tap here to enter text. ☐ Excessive sweating Click or tap here to enter text. ☒ Diabetes DM type II ☐ Other Click or tap here to enter text.
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O: Objective
Information gathered during the physical examination by inspection, palpation, auscultation, and percussion. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings. Pertinent positive are the “abnormal” findings and pertinent “negative” are the expected normal findings. Separate the assessment findings accordingly and be detailed.
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Body System |
Positive Findings
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Negative Findings |
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General
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Unable to assess |
Click or tap here to enter text. |
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Skin
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Unable to assess |
Click or tap here to enter text. |
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HEENT
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Unable to assess Click or tap here to enter text.
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Click or tap here to enter text. |
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Respiratory
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Unable to assess |
Click or tap here to enter text. |
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Neuro
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clinical evaluation for mental status: WDL Clinical evaluation for sensation in the BUE and BLE: intact, expected, no abnormalities. WNL, Clinical evaluation for Point to point movements and coordination: expected, symmetry, steady, WDL. Hypoglossal nerve: symmetry, WDL Evaluation of accessory muscles and neck: WDL, full range of motion Tendon reflexes: expected, active +2, WDL Glossopharyngeal and vagus nerve: WDL, intact. Auditory nerve: intact, normal, WDL. Head and facial nerve: WDL, normal. Symmetry. Weber test and Rinne test: WDL, normal. Facial sensation: WDL Ocular nerves: WDL, normal, no visible abnormal findings PERRLA: pupils are equal , round, react to light and accommodation, Optic nerves: WDL, no visible abnormal findings Visual acuity:20/100 bilaterally Olfactory nerve: able to discriminate and symmetry Vocabulary, comprehension, attention span, abstract thinking, and articulation: WDL, abstract thinking, accurate, no problems noted. Memory, orientation and general knowledge: WDL, alert and oriented x 4, intact, accurate, and able to follow commands. : |
Click or tap here to enter text. |
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Cardiovascular
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Unable to assess |
Click or tap here to enter text. |
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Musculoskeletal
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Unable to assess |
Click or tap here to enter text. |
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Gastrointestinal
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Unable to assess |
Click or tap here to enter text. |
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Genitourinary
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Unable to assess |
Click or tap here to enter text. |
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Psychiatric
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Unable to assess |
Click or tap here to enter text. |
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Gynecological
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Unable to assess |
Click or tap here to enter text. |
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Problem List |
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| Neck injury |
6. Click or tap here to enter text. |
11. Click or tap here to enter text. |
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2. Migraines |
7. Click or tap here to enter text. |
12. Click or tap here to enter text. |
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3. Meningitis |
8. Click or tap here to enter text. |
13. Click or tap here to enter text. |
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4. Click or tap here to enter text. |
9. Click or tap here to enter text. |
14. Click or tap here to enter text. |
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5. Click or tap here to enter text. |
10. Click or tap here to enter text. |
15. Click or tap here to enter text. |
A: Assessment
Medical Diagnoses. Provide 3 differential diagnoses (DDx) which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis.
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Diagnosis |
ICD-10 Code |
Pertinent Findings |
| Neck Injury | S19.9XXA | Neck injury as result of car accident, patient complains of soreness and pain in the neck that increase with ambulation and activity. |
| Post traumatic headaches | G44.309 | Intermittent headaches after car accident that comes and goes, dull ache, kind of in the crown of my head, and the back of my head |
| Meningitis | G03.9 | Pt complained of soreness and stiffness in the neck and headaches, pt denied any other symptoms by evaluating is needed to rule out meningitis |
P: Plan
Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but do not leave any heading blank. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention.
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Diagnostics: List tests you will order this visit |
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Test |
Rationale/Citation |
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| Glasgow coma scale and increase in ICP. | Glasgow come scale assess patient level of orientation and alertness. A neurological scale helps to identify patient initial state and subsequent assessment. ICP: need to monitor change sin LOC or widening pulse pressure, bradycardia, bounding pulse and assessing the severity and frequency of headaches. | ||
| Kerning’s sign, lumbar puncture with CSF and analysis, culture and sensitivity of CSF, CT scan, MRI | Kerning’s signs is a valuable test because it helps to determine a positive meningitis. Lumbar puncture is essential to determine viral versus bacterial infection by obtaining a sample of the cerebral spinal fluid. Culture and sensitive of the CSF is important to determine the line of treatments according to the bacteria found in the fluid (it helps to choose proper antibiotics treatment). CT scan and MRI helps to determined inflammation of the meninges, very important test to diagnose meningitis. | ||
| BUN, creatinine, electrolytes, CBC | CBC: abnormal or elevated WBC can indicates infection; current renal function need to be evaluated if pt will start antibiotics specially when placing a patient in vancomycin or aggressive antibiotics treatment s to fight infections. Electrolytes need to be monitor to prevent seizures specially sodium. Amy pt positive for meningitis is already at risk of seizure, decreased in LOC result in decrease of nutrition, electrolytes needs to be monitor closely to prevent seizures and cardiac dysfunction. | ||
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Medications: List medications/treatments including OTC drugs you will order and “continue meds” if pertinent. |
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Drug |
Dosage |
Length of Treatment |
Rationale/Citation |
| Ibuprofen | 400 mg every 4 to 6 hours | 30 days | For moderate pain of neck and headache |
| Heat and ice packs | One pack every Q2 alternate between cold and heat | 30 days | For neck swelling and soreness |
| Penicillin ( cephalosporin) | 500 mg q12 | 14 days | For possible meningitis |
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Referral/Consults: |
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Chiropractic referral depending on clinical findings in x ray follow up at the clinic in 5-7 days for continuity of monitoring headaches and neck pain, Neurologist Evaluations
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If patient is negative for meningitis, then pt needs follow up of care at the clinic and by a chiropractic to assess any neck injury and help to decrease soreness and improve the ability of full range of motions. If patient is positive for meningitis, a referral with neurologist is essential to treat patient symptoms and plan of care. | Click or tap here to enter text. | |
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Education: |
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Patient education in regards Chiropractic referral, control of pain and use of heat and old intervention to manage neck soreness |
Rationale/Citation control of pain and use of heat and old intervention to manage neck soreness | Click or tap here to enter text. | |
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Follow Up: Indicate when patient should return to clinic and provide detailed symptomatology indicating if the patient should return sooner than scheduled or seek attention elsewhere. |
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Pt must return in 5-7 days to monitor headaches and neck soreness and effectively of prescribed ibuprofen for moderate pain |
Rationale/Citation | Click or tap here to enter text. | |
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References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct current APA edition formatting. |
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| Chen, L., Xu, Y., Liu, C., Huang, H., Zhong, X., Ma, C., ...Chen, Y. (2020). Clinical features of aseptic meningitis with varicella zoster virus infection diagnosed by next-generation sequencing: case reports. BMC Infectious Diseases, 20(1), NA. Retrieved from https://link.gale.com/apps/doc/A627548276/AONE?u=fjp_jvpl&sid=AONE&xid=84d8160a Pomar, V., de Benito, N., Mauri, A., Coll, P., Gurguí, M., & Domingo, P. (2020). Characteristics and outcome of spontaneous bacterial meningitis in patients with diabetes mellitus. BMC Infectious Diseases, 20(1), NA. Retrieved from https://link.gale.com/apps/doc/A627351314/AONE?u=fjp_jvpl&sid=AONE&xid=3bc360a8 Maher, A. B. (1985, March). Dealing with head and neck injuries. RN, 48, 43+. Retrieved from https://link.gale.com/apps/doc/A3667862/AONE?u=fjp_jvpl&sid=AONE&xid=52a0770c | |||
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