Neurological SOAP Note PDF

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Neurological SOAP Note

Barbra Scheirer Regis College NU 650- Advanced Health Assessment Professor T. Hewitt November 28, 2021

2 Neurological SOAP Note Date: 11/247/2021 1530 hrs. Patient name: S.G. Race/Ethnicity: Black DOB: 3/15/1957 Age: 64Y F Marital Status: Married SUBJECTIVE Chief Complaint (CC): "My face is drooping” History of Present Illness (HPI): The patient is a 64-year-old black married female. The patient is her own reporter and seems reliable. The patient is A+O x4. The patient is here for a complaint of right-sided facial droop. The patient denies any actual injury. The patient states she woke up this morning with a little tingling in her right lip but did not think much about it until she was trying to drink her morning coffee, and it dribbled out of her mouth. Her husband told her that her face looked funny. She states when she looked in the mirror, she noticed the right side of her face was drooping. She states over the course of several hours it has gotten worse and now she cannot close her right eye. The patient also mentions her taste is altered. The patient has not tried any medications or home remedies for her symptoms. Review of Systems (ROS): 

General: 64-year-old black female appears stated age, in no apparent distress. Alert, oriented, and cooperative. Able to speak in full sentences and does not appear breathless. Pt denies fever, weakness, fatigue, nightly sweats, and shortness of breath.

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Skin: The patient denies rashes or other skin changes. The patient denies breast lumps, pain, skin changes, and nipple discharge. The patient denies any lumps tenderness, or rash in the axilla.

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Hair/nails: The patient denies abnormal/excessive hair loss, change in texture, or change in nail color, shape, or brittleness.

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HEENT: No history of head injury. The patient denies headaches. The patient denies issues with her vision but does state her right eye is dry. Her last eye exam was 2 years ago. The patient states she cannot close her right eyelid or move her right eyebrow. The patient denies any problems with her hearing. The patient states she has pain behind her right ear. The patient denies vertigo, tinnitus, and discharge. Patient denies frequent colds or sinus infections, runny nose, discharge, sinus pain, and nose bleeds. The patient denies nasal congestion, sore throat, and difficulty swallowing. The patient denies lumps, swollen glands, goiter, pain, and stiffness. The patient denies loose teeth, bleeding gums, dental caries, and halitosis. She reports having her own natural teeth. She reports her last dental exam was 2 years ago. The patient states she dribbles when she attempts to drink liquids. The patient states her smile is also uneven.

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Respiratory: Patient denies any SOB, DOE, cough, and sneezing.

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Cardiovascular: The patient denies chest pain, palpitations, DOE, shortness of breath, orthopnea, and murmur.

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Peripheral Vascular: The patient denies leg cramps, varicose veins, history of clots, coldness, numbness, and darkening of skin to lower legs. The patient denies swelling to her lower legs.

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Musculoskeletal system: The patient denies any weakness and pain to any muscles or joints.

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Neuro: The patient denies fainting, blackouts, seizures, weakness or paralysis of the arms or legs, vertigo, numbness, or tingling. The patient reports she does not have any difficulty with walking and does not use any assistive devices.

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Gastrointestinal: Appetite good; no nausea or vomiting. Denies belching, flatulence, and hiccups. Bowel movement about once daily, no diarrhea or bleeding. No pain, jaundice, gallbladder, or liver problems.

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Urinary: The patient denies frequency, urgency, burning, nocturia, polyuria, hesitancy, straining. The patient reports she is in a monogamous relationship does not use condoms. She denies sores and drainage to her genitalia.

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Hematologic: The patient denies a history of anemia. The patient denies bruising, bleeding, and transfusion history.

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Endocrine: The patient denies a history of diabetes, excessive thirst, hunger, urination. The patient is post-menopausal.

Past Medical History (PMH): Hypertension, age 49. High cholesterol, age 49. Mild depression, age 50, Chicken pox at age 4, and no other childhood illness. No medical or psychiatric hospitalizations. Social History: The patient is married and lives with her husband. She is a registration clerk for a surgery center for the past 17 years. The patient has a 2-year college degree. The patient identifies as Baptist. The patient reports she eats well. The patient smokes 3-4 cigarettes several times a week. Patient states she is a social drinker and drinks a cocktail or two a couple times a

5 month. She denies past and current use of any drugs. CAGE screening is 0. The patient does not participate in any risky activities. Past Surgical History: Gallbladder, age 41, and a hernia repair, age 37. Family History: The patient has a younger sister who is healthy. The patient has two children, both girls-and are healthy. Her mother is alive, age 85, and has a history of high blood pressure and in in remission for breast cancer. Her father is alive, age 86, and has a history of dementia. PGM: died from unknown causes, PGF: died at age 78 from a heart attack . MGM: died at 89, from a stroke. MGF: died at 81 from complications of diabetes. Medications: Lisinopril 5 mg p.o. daily, Aspirin 81 mg p.o. daily, Multi-vitamin 1 tablet p.o. daily, Motrin 600-800 mg p.o. every 6-8 hours as needed for inflammation/pain Immunizations: Up to date; received tetanus booster and influenza vaccines this year and completed her single shot Covid vaccine in March of this year. Pneumonia shot was last year Allergies: None Functional assessment: Health Maintenance Practices 

Activity/exercise: Daily 20-minute walks in her neighborhood, 3-4 times a week.

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Sleep/rest: She reports averaging about 6-7 hours of uninterrupted sleep per night.

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Nutrition/elimination: The patient eats a regular diet of 3 meals and one snack per day. The patient reports no issues with elimination.

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Relationships/resources: She reports she is married, and her spouse is supportive. She reports positive relationships with her sibling and friends.

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Spirituality: Patient reports being Baptist and attends church regularly.

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Coping and stress management: The patient denies feelings of stress or anxiety and does practice stress management techniques as needed.

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Safety: She reports being safe in the home. There are no firearms in the house. She wears a seatbelt while in the car and does not participate in any risky activities. The patient reports wearing sunscreen on her face daily and on her body only when spending extended time outdoors.

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Screenings: Vision and hearing screening, mammogram, PAP test, and colon cancer screenings last year, which were all negative.

OBJECTIVE 

General: 64-year-old African American female appears stated age in no apparent distress. Alert, oriented, and cooperative. Able to speak clearly in full sentences and does not appear breathless on this visit.

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Vital signs: Temp: 98.5, BP: 176/89, HR: 100, RR: 18, O2: 99 % RA.

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Height: 66 inches Weight: 181 BMI: 29.2 (overweight)

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Labs: visit date: 1/2019-all normal

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HEENT: Head normo-cephalic. No deformities, lumps, depressions noted. Hair thick and distribution even throughout the scalp. Normal/symmetrical contour of the face with relaxed facial expression. No edema, masses, or involuntary movements noted. Eyes: Sclera clear. Conjunctiva: white, Lacrimal apparatus intact, palpebral fissures symmetrical and adequate. Eyebrows asymmetrical. Cornea, lenses intact, no opacities noted, PERRLA, EOMs intact. Visual acuity 20/30. No extraocular movements or

7 nystagmus noted. Lid drooping noted on right side. Normal ophthalmic exam. Unable to close right eye. Ears: Tympanic membranes shiny, grey, and intact. No drainage noted. No foreign bodies or excessive ear wax noted. External Ear no lesions, masses, swelling, or deformities noted. Auricles symmetrical, no deformities, lumps, or lesions noted. Acuity is good to whispered voice. Normal Weber and Rinne tests. Nose: Color pink. No discharge. Septum midline. No bleeding, ulcers, or polyps. No tenderness noted in frontal or maxillary sinuses—olfactory function normal. Mouth: Lips red and moist, no cracking, moist mucous membranes, no thrush, no vesicles, no lesions, good dentition. No loose teeth. Tongue: pink, no lesions or discoloration. Gums and Mucosa: pink, no swelling, bleeding, or infection. Throat: Pharynx and Tonsillar Fossa: normal. Tonsils: present, 1+, hard and soft palates are normal. Thyroid: normal, non-tender, no nodules noted. Trachea: midline, no nodules noted. 

Lymph Nodes: All lymph nodes are non-palpable and non-tender.

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Respiratory: Respiratory rate of 20. Breathing easy with symmetrical chest rise, no cyanosis. Thorax is non-tender, symmetric with good expansion and fremitus. Lungs are resonant. No areas of abnormal dullness. Breath sounds clear, with no adventitious sounds noted.

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Cardiovascular: HR regular, rate of 100, JVP normal-2 cm above sternal angle with head of bed at 30 degrees. Carotid upstrokes are brisk, without bruits—no lifts, thrills, crepitus, or tenderness with palpation on anterior chest. The PMI is tapping, 1 cm lateral to the midclavicular line in the 5th intercostal space. S1 and S2 sounds normal. There are no murmurs or extra sounds. Mitral stenosis and aortic regurgitation not noted with auscultation.

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Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly noted, no bruits noted. No tenderness noted. Aorta width palpated to be 2cm. Rovsing sign, psoas sign, obturator sign, Murphy’s sign, and McBurney’s signs are all negative.

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Peripheral Vascular System: Skin color, temperature, and moisture are normal. No edema, varicosities or stasis changes noted. Calves are supple and non-tender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis and posterior tibial pulses are 2+ and symmetric. Epitrochlear nodes and axillary lymph nodes palpable and normal. Arterial perfusion normal with Allen test.

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Musculoskeletal: Overall normal musculature noted. Normal gait noted. Full range of motion and strength in all joints. Negative McMurry’s test, negative Valgus and Varus stress tests. Negative anterior and posterior drawer signs. Negative Finkelstein test. No bulge or balloon sign. No deformities, abnormalities or tenderness noted to all joints. No pain with flexion, extension, or rotation of the shoulders, hips, or spine. Spine noted to have normal curvatures and in normal alignment with no pain or tenderness noted. Negative Hawkin sign, arm drop, and neer-impingement signs. Phalen and Tinel tests are negative. No baker’s cysts noted or pain to back of knees.

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Cranial nerves: CN 7-abnormal-right sided facial droop noted. Loss of right sided brow movement, unable to close right eye, right eye drooping noted, right nasolabial fold flattened, drooping of lower lip. All other cranial nerves intact and WNL. Coordination: There are no abnormal or extraneous movements. The posture is normal. Gait is steady with normal steps, base, arm swing, and turning. Heel and toe walking are normal. Motor system: Muscle bulk and tone are normal. Strength is full bilaterally. R/L

9 arm flex and ex 5/5 muscle strength against full resistance. Sensory: Light touch, pinprick, are intact in face, fingers and toes. Reflexes: Right Biceps: 2+ (normal). Left Biceps: 2+ (normal). Right Triceps: 2+ (normal). Left Triceps: 2+ (normal). Right Patella: 2+ (normal). Left Patella: 2+ (normal). Right Ankle: 2+ (normal). Left Ankle: 2+ (normal). ASSESSMENT Differential Diagnosis: Bell’s Palsy, Lyme disease, Acute Stroke Bell’s Palsy: Bell’s Palsy is a sudden, temporary paralysis of the facial nerve that controls the forehead, eyelid, face, and neck (Kline et al., 2021). This results from damage to the seventh cranial nerve. It begins suddenly and worsens over 48 hours, and it usually only affects one side of the face (Kline et al., 2021). Peripheral facial nerve palsy can be distinguished clinically from central facial palsy (due to stroke) by its involvement of the muscles of the forehead (Heckmann et al., 2019). The typical features of peripheral facial nerve palsy are a lack of wrinkling of the forehead, low eyebrow position (eyebrow ptosis), incomplete lid closure, hanging corner of the mouth, and a flattened nasolabial fold (Heckmann et al., 2019). Lyme disease: Lyme disease is a bacterial infection caused the bacterium Borrelia burgdorferi being transmitted through a tick bite (Wright et al., 2012). Symptoms of Lyme disease can include a red bullseye rash, fever, joint pain and facial drooping (Schoen, 2020). About five percent of patients with Lyme disease will develop some degree of sudden facial weakness, where one or both sides of the face droop (Hatchette et al., 2014). Known as Lyme diseaseassociated facial palsy, this tends to occur seven to 21 days after tick exposure in infected patients (Hatchette et al., 2014).

10 Acute Stroke: An acute stroke, or cerebral vascular accident occurs when there is a reduction or blockage of blood supplied to the brain . There are two types of strokes: a thrombus (blockage) blockage and hemorrhage (bleed). The symptoms of both types are the same and are determined by where the insult is in the brain. Symptoms can include paresthesia or paralysis to parts of the body on one side, facial droop, altered level of conscious, headache with vomiting, slurred speech, difficulty swallowing and trouble walking (Yew & Cheng, 2015).

PLAN 

Labs: CBC, CMP, Lipid panel, CRP, ESR, and Lyme titer, The most accurate test for Lyme disease is with a two-step blood test. The first is a screening test called am enzymelinked immunosorbent assay, or ELISA, which looks for certain antibodies of the body’s immune system (Schoen, 2020). With a positive test, the Western blot test is the definitive diagnosis of Lyme disease (Schoen, 2020).

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Tests: Head CT

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Pharmacologic interventions: Continue current medications. Treatment for Bell’s palsy is to reduce nerve inflammation and limit nerve damage (Hato et al., 2007). Prednisone 60 mg p.o. daily x 10 days, then taper for 10 days and Valacyclovir 1000 mg p.o. daily x 5 days (Hato et al., 2007) (Gagyor et al., 2015). Treatment with a steroid and an antiviral agent resulted in significantly higher recovery rate than steroids alone (Kang et al., 2014).

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Non-pharmacologic intervention: Non pharmacologic treatments can include using lubricating eye drops, facial massage, physical therapy, electrical stimulation, and acupuncture (Estes, 2019).

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Referrals: Neurology and Ophthalmology in 1 week (Heckmann et al., 2019). Go to Urgent care or Emergency Room if worsening

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Education: Patient education is vital to reduce the risk of complications through selfmanagement regimes. These include issues such as dealing with dry eyes and mouth, how to tape an eye shut as to avoid dealing with eating and drinking, a new development of facial expression, speech, and language adjustments (Walker et al., 2021). Additionally, some patients with facial nerve palsies find charities and support groups helpful to meet like-minded people to share ideas and collaborate on how best to manage the condition. would educate the patient on her diagnosis, along with education of the disease process (Walker et al., 2021). I would also educate the patient on blood pressure and cholesterol control. I would also include health maintenance recommendations as appropriate for her to include a heart healthy, low fat diet, smoking cessation, weight management, cancer screenings, depression screening, intimate partner violence screening, and drug and alcohol screening. Education of prescribed medications will also be shared.

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Follow up: 3 weeks. If symptoms worsen or persist, go to nearest Urgent Care or Emergency Room.

12 References Estes, M. (2019). Non-pharmacologic therapies for management of long-term sequela of Bell's palsy. UCLA Health, 23. https://www.preoceedings.med.ucla.edu/wpcontent/uploads/2019/02/estes-a19011ME-BLM-edited.pdf Gagyor, I., Madhok, V., Daly, F., Somasundara, D., Sullivan, M., Gammie, F., & Sullivan, F. (2015). Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd001869.pub8 Hatchette, T., Davis, I., & Johnston, B. (2014). Lyme disease: Clinical diagnosis and treatment. Canada Communicable Disease Report, 40(11), 194–208. https://doi.org/10.14745/ccdr.v40i11a01 Hato, N., Yamada, H., Kohno, H., Matsumoto, S., Honda, N., Gyo, K., Fukuda, S., Furuta, Y., Ohtani, F., Aizawa, H., Inamura, H., Murakami, S., Kiguchi, J., Yamano, K., Takeda, T., Hamada, M., & Yamakawa, K. (2007). Valacyclovir and prednisolone treatment for Bell's palsy. Otology & Neurotology, 28(3), 408–413. https://doi.org/10.1097/01.mao.0000265190.29969.12 Heckmann, J., Urban, P., Pitz, S., Guntinas-Lichius, O., & Gágyor, I. (2019). The diagnosis and treatment of idiopathic facial paresis (Bell's palsy). Deutsches Aerzteblatt Online. https://doi.org/10.3238/arztebl.2019.0692 Kang, H., Jung, S., Byun, J., Park, M., & Yeo, S. (2014). Steroid plus antiviral treatment for Bell's palsy. Journal of Internal Medicine, 277(5), 532–539. https://doi.org/10.1111/joim.12288 Kline, L., Kates, M., & Tavakoli, M. (2021). Bell palsy. JAMA, 326(19), 1983. https://doi.org/10.1001/jama.2021.18504

13 Schoen, R. (2020). Lyme disease: Diagnosis and treatment. Current Opinion in Rheumatology, 32(3), 247–254. https://doi.org/10.1097/bor.0000000000000698 Walker, N., Mistry, R., & Mazzoni, T. (2021). Facial nerve palsy. StatPearls. Retrieved November 24, 2021, from https://www.ncbi.nih.gov/books/nbk549815/ Wright, W., Reidel, D., Talwani, R., & Gilliam, B. (2012). Diagnosis and management of Lyme disease. Ammerican Family Physician, 85(11), 1086–1093. https://www.afp/2012/0601/afp20120601p1086.pdf Yew, K., & Cheng, E. (2015). Diagnosis of acute stroke. American Famiily Physician, 91(8), 528–536. https://www.aafp.org/afp/2015/0415/p258.html...