SOAP note for Tina Jones on neurologic assessment

SOAP Note For Tina Jones On Neurologic Assessment

SOAP note for Tina Jones on neurologic assessment. (Shadow health assignment, neurologic assessment).

Please see shadow health on tina jones neurologic assessment for the assignment.

SOAP Note Format

Patient Information:

• Initials
• Age
• Sex
• Race
• Insurance

Subjective

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: include all the information regarding the CC using the OLDCART format. If the CC was “Unintentional weight loss”, the OLDCART for the HPI might look like the following example:

Onset: 2 months ago

Location: Generalized

Duration: Steady weight loss, 3-5 pounds per week

Characteristics: Associated with feeling tired, poor appetite, and occasional nausea without vomiting

Aggravating Factors: Food smells increase the frequency of nausea

Relieving Factors: Small, bland meals are better tolerated

Treatment: None reported

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately.

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use, any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses.

Reasons for the death of any deceased first degree relatives should be included.

Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS

Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: Constitutional: Head: EENT: etc. You may list these in paragraph format or bullet format. Always document the systems in order from head to toe. You may focus the ROS to match the chief complaint unless you are doing a complete health history.

Example of Complete ROS:

CONSTITUTIONAL: No weight loss, fever, chills, weakness or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: No history of asthma, hives, eczema or rhinitis.

Objective

Physical exam: include the same body systems as in the ROS. Include the assessment data for the system(s) identified in the discussion instructions. Always document in head to toe format i.e. Constitutional: Head: EENT: etc.

Diagnostic results: when available (from today and past recent tests results if pertinent)

Assessment

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. Include the ICD9 or ICD10 codes in parentheses next to the diagnosis. Include pertinent positive and negative findings to support your diagnoses from the history and physical exam. SOAP note for Tina Jones on neurologic assessment

No intervention is self-evident. Provide a rationale and evidence based in-text citation for each intervention

Diagnostics: list tests you will order this visit

Rx: list treatments and medications you will order and “continue previous meds” if pertinent. State dosages, length of treatment and reason for choosing a specific treatment or drug.

Education: think about covering yourself legally; also indicate when written instructions are given.

Referral/Consults: (if any)

SOAP note for Tina Jones on neurologic assessment

Follow up: indicate when a patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere.

References

You are required to include at least one evidence based peer-reviewed journal article which relates to this case. Be sure to use correct APA 6th edition formatting.

Pre Brief

Two days after a minor, low-speed car accident in which Tina was a passenger, she noticed daily bilateral headaches along with neck stiffness. She reports that it hurts to move her neck, and she believes her neck might be swollen. She did not lose consciousness in the accident and denies changes in level of consciousness since that time.

She states that she gets a headache every day that lasts approximately 1-2 hours. She occasionally takes 650 mg of over the counter Tylenol with relief of the pain. This case study will allow you the opportunity to examine the patient’s optic nerve via use of the ophthalmoscope as well as assess her visual acuity. You will need to document your findings using appropriate medical terminology. Be sure to assess for foot neuropathy using the monofilament test.

Reason for visit: Patient presents complaining of headache.