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NEURO_SOAPSamplecopy.pdf
RUNNINGHEAD: NEURO SOAP NOTE 1
Neurological Exam Soap Note Week
United States University: MSN 572
August 9, 2021
Dr. Tolulope Adedayo
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NEURO SOAP NOTE 2
ID: M.J. DOB 03/18/1978, 43-year-old married Black male presents to the office today
accompanied by his wife.
Subjective
Chief complaint
“My face feels like it’s numb.”
History of Present Illness
M.J is a43-year-old black male born and raised in California, who presents to the clinic today
with complaints of his face “feels like it’s numb.” His symptoms began two days ago at work and
has been constant, with the right side of his face feeling more numb than the left side. M.J has
worked for the Department of Motor Vehicles for the past 15 years. His schedule is Monday thru
Friday, 9am to 5pm weekly. He states that he has been feeling extremely overwhelmed at work
related to an increased workload and unrealistic expectations from his managers. He states that
he feels his managers are “out to fire him”, and this is the cause of his distress.
Primary Medical History
Allergies: No known Drug Allergies
PMH: No past medical history. No history of viral infection, hypertension, diabetes, or
migraines. Last doctor’s visit 1 year ago for annual physical exam.
Surgical History: Drainage of rectal abscess 10 years ago.
Immunizations: Childhood immunizations up-to-date to the best of his knowledge. Has never
received the flu vaccine. Received Pfizer Covid vaccine 3/2021.
Family history: Mother is in her early 50's and is overweight with no known medical conditions.
Father is alive in his late 50’s and has hypertension and high cholesterol. He is unaware of any
medical conditions to his maternal grandparents, who are alive and separated. His paternal
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NEURO SOAP NOTE 3
grandfather passed away ten years ago from colon cancer and his paternal grandmother is alive
in her 70’s and has a history of COPD. He has one younger brother, age 38, with no known
medical history. His three school-age children are healthy with no medical history.
Medications: Does not take any prescription or OTC medications.
Social History
Marital history: Married for 13 years
Occupation: State employee for 15 years at the Department of Motor Vehicles.
Diet/exercise: Drinks an adequate amount of water throughout the day and eats about two big
meals with a snack. His usual meal consists of take-out food for lunch or leftover dinner with
rice, vegetables, and protein. He may eat oatmeal at work for breakfast.
Spiritual: Christian
Safety: M.J is a registered gun owner and keeps his firearm in a locked safe, away from his
family. Wears a helmet when riding his motorcycle 100% of the time. Wears a seatbelt 100% of
the time.
Sexual/Reproductive: In a monogamous relationship.
Drug use: Occasionally uses marijuana once or twice a month, usually when he’s with friends.
Last use was 3 weeks ago. First use as a teen.
Alcohol use: Denies use of alcohol.
Tobacco: Denies smoking cigarettes, vaping, or e-cigs.
Sleep: Sleeps 6-8 hours a night. Denies waking up throughout the night.
Review of Systems
Constitutional: Denies pain, fever, and chills. Denies any weight changes.
Integumentary: Denies any rashes, bruises, open wounds, lesions, or cuts to skin.
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NEURO SOAP NOTE 4
HEENT: Patient wears prescription glasses, denies any vision changes, blurriness or diplopia.
Denies sore throat, dysphagia, problems smelling. Reports dry eyes for past two days. Reports
increased sensitivity to loud noise such as the vacuum and music. Reports discomfort located in
the right postauricular area lasting for 30 minutes, beginning at work. Patient stated he drank
more water and eventually it went away. Pain level was described as 5/10. No history of chronic
headaches. Reports changes in taste, such as food tasting “more bland than usual”.
Pulmonary: Denies shortness of breath, dyspnea, cough.
Cardiovascular: Denies chest pain or abnormal swelling to his extremities.
Gastrointestinal: Denies nausea, vomiting, diarrhea, or constipation.
Genitourinary: Denies any pain, bleeding, burning, frequency, retention, or hesitancy with
urination.
Neurological: Denies any recent falls. Denies dizziness, seizures, light-headedness. Denies any
trauma. Denies any numbness to bilateral hands, feet, arms, legs, and toes. Reports numbness to
right side of face and lip area, does not include the orbital area.
Musculoskeletal: Denies any weakness to upper and lower extremities.
Psychological: Denies feelings of hopelessness, despair, intent to hurt self or others. Verbalizes
feelings of frustration and being upset due to work related issues. Sleeps 6-7 hours a night, and
does not awaken throughout the night.
Allergy/Immunology: Denies any current or previous hematologic disorders. Denies any current
or previous systemic disorders. Denies allergies to food, pets, environmental, and medications.
Denies any abnormal bleeding or bruising.
Objective
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NEURO SOAP NOTE 5
Vital Signs: BP: 138/65. Temp: 98.9 F Pulse: 85 RR:18 O2 sat: 100% RA. Current weight and
height: 6’0, 180 lbs., BMI: 24.4, normal.
Integumentary: General skin color is normal for ethnicity. No skin rashes, lesions, open wounds,
or scars noted. Skin turgor is normal.
Lymphatic: No swelling or tenderness to the bilateral occipital, temporal, mandibular, submental,
preauricular or tonsillar lymph nodes. Swelling and tenderness noted to right post auricular area.
Head: Head contour and shape is normal with no visible deformities or trauma noted. No
depressions, lesions, rashes or hematomas noted upon palpation. No tenderness or swelling
palpated to frontal or maxillary sinuses.
Ears: No drainage noted to bilateral ears. No redness or swelling noted bilaterally to auditory
canal. Tympanic membrane is pearly gray. Five o’clock cone of light to right ear. Seven o’clock
cone of light cone to left ear present. Whisper test is negative, patient is able to repeat whispered
word to bilateral ears.
Eyes: Patient wears prescription glasses. PERRLA intact. CN II, III, IV, VI intact. Confrontation
is positive OD, OS. Negative for nystagmus. Sclera is white. Red reflex intact. Disc to cup ratio
is 3:1, and disc is sharp to OD, OS. Conjunctiva is pink, dryness noted to OS, OD.
Nose: Nasal septum midline. No postnasal drip, drainage, redness, lacerations or swelling noted
to nasal canal/mucosa.
Mouth: No redness, swelling, bleeding noted to oral mucosa. Oral mucosa is moist and normal
color for ethnicity. CN X & IX intact. No swelling or inflammation noted to posterior pharynx,
tonsils and soft palate. Tongue is midline.
Throat: Trachea is symmetrical with no deviation. No swelling or tenderness of the thyroid
gland.
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NEURO SOAP NOTE 6
Pulmonary/Thorax: Respirations are even and unlabored. No signs of dyspnea. Posterior, lateral,
and anterior lung sounds are clear with no adventitious sounds. No use of accessory muscles
noted.
Gastrointestinal: Abdomen is soft, flat, nontender, no visible pulsations noted. Last BM today-
normal consistency and frequency for patient.
Genitourinary: Bladder is soft, nontender.
Musculoskeletal: ROM and motor strength to upper and lower extremities intact, 5+.
Cardiovascular: S1 and S2 present. No thrills palpated. No bruits or murmurs upon auscultation.
Rate and rhythm are regular at 89 beats/minute. No swelling noted to upper and lower
extremities. Capillary refill to fingernails and toenails 3+. No clubbing or cyanosis noted to
fingers and toes.
Neurological: Speech is clear and concise. Alert and oriented x4. CN I (olfactory) intact, patient
is able to smell appropriately in both nares. CN II (optic) intact, vision is 20/20 with prescription
eyeglasses in place. CN III (oculomotor) intact, patient is able to , IV (trochlear), V (trigeminal),
VI (abducens), VIII (acoustic), IX (glossopharyngeal), XII (hypoglossal) intact. DTR to bilateral
biceps, triceps, patellar, and Achilles 2+. Weakness noted to CN VII (facial). Smile is unequal on
the right side. Difficulty raising right eyebrow. No facial drooping noted.
Assessment
Differential Diagnosis:
1. Bell Palsy ICD G51.0- CN VII weakness noted. Impaired ability to raise ipsilateral
eyebrow, impaired ability to smile, tenderness to right postauricular lymph node area,
decreased tearing/dryness to eyes, changes in taste (Domino, 2022).
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NEURO SOAP NOTE 7
2. Acute Stroke ICD I63.9- Complaints of numbness and tingling to right side of face. No
facial drooping noted. Romberg and pronator drift negative. Speech is clear and coherent.
No changes in vision. No changes in gait or balance.
3. Guillen-Barre Syndrome G61.0- Cranial nerve VII weakness to the right side of the face
and complaints of paresthesia. No progressive limb weakness. CN V motor and sensory
function intact. ROM and motor strength to upper and lower extremities intact, 5+.
Steady gait, no c/o dizziness. DTR of biceps, triceps, patellar, Achilles 2+. No recent flu
vaccinations, GI, or respiratory infections. Vital signs within normal limits.
Final Diagnosis:
Bell Palsy- inflammation of CN VII triggered by event related stressor.
Plan
Diagnostic Labs & Studies:
CBC, CRP/ESR
HIV test, rapid plasma reagin (RPR) test.
Lyme serology: ELISA or IFA, Western blot for IgM, IgG for Borrelia burgdorferi
Titers for Varicella zoster virus, rubella, cytomegalovirus, hepatitis A, B, C.
Electromyography (EMG) if paralysis lasts more than one week.
Facial/skull radiography, CT scan or MRI to rule out stroke, facial fracture, tumor, or
neoplasms. (Domino, 2022)
Treatment: Prednisone 60mg oral daily for the first 5 days. Then, taper dose by 10mg/day for the
next five days. Valacyclovir 1,000 mg three times daily for seven days. Ibuprofen 600 mg oral
every 6 hours as needed for moderate-severe pain 5-10. May alternate with acetaminophen for
breakthrough pain 1,000 mg oral every 6 hours as needed (Domino, 2022)
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NEURO SOAP NOTE 8
Patient teaching:
May use cold or heat packs for 10-20 minutes at a time, four times a day for pain relief.
Make sure not to apply cold pack directly to skin, rather wrap it in a towel first to prevent
frost bite.
Wear eye protection during the day. Taping the affected eye at night and using lubricating
eyedrops or ointment will keep the eyes from drying out and remaining moist.
Take analgesics as needed.
Referrals: Refer to an ENT or ophthalmology specialist if ocular complications arise. A referral
to a neurologist may be warranted if symptoms worsen or do not resolve adequately after four
weeks.
Follow up: Follow up with PCP in four weeks, or sooner, if symptoms worsen or do not resolve.
Report any new changes to vision, trouble walking, or headaches.
References
Cash, J. C., & Glass, C. A. (Eds.). (2017). Family Practice Guidelines. New York; Springer
Publishing Company.
Domino, F.J., Baldor, R.A., Berry, K., Golding, J., & Stephens, M.B. (2022). The 5-minute
clinical consult 2022. Lippincott Williams & Wilkins.
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