NR 509 SOAP Note week 3 Neuro shadow health PDF

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Summary

Week three shadow health assignment for NR509 SOAP Note completed document. received full credit for this assignment....

Description

SOAP Note Template S: Subjective Information the patient or patient representative told you Initials: TJ

Age: 28

Height

Weight

BP

HR

RR

Temp

SPO2

170 cm

88kg BMI: 30.5

139/ 87

82

16

98.9

99%

Gender: female Pain Rating

Allergies (and reaction)

Medication: penicillin hives. Food: none Environment: cats respiratory difficulty.

History of Present Illness (HPI) Chief Complaint (CC) Headache and neck pain after fender-bender. Onset Accident one week ago symptoms occurred 2 days after Location Parking lot Duration

1-2 hours

Characteristics

Dull ache not cluster or cyclic or sharp.

Aggravating Factors

Head or neck movement.

Relieving Factors

Rest and Tylenol

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

Treatment Rest and Tylenol until further evaluation Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Length of Time Medication Reason for Use Dosage Frequency (Rx, OTC, or Homeopathic) Used Tylenol 2 tabs regular strength Once daily At onset of pain Head and neck pain post fender 5 days bender. Proventil inhaler Two 90 mcg puffs PRN Since 2.5 years Asthma exacerbation old Flovent 2 puffs of 44 mcg BID Unknown asthma Click or tap here to enter text. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text. enter text. text. to enter text. Click or tap here to enter text. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.

enter text.

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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.

Immunization up to date. Last tetanus booster was received previous year. Currently headaches and neck pain. Past major illnesses include Asthma, & diabetes. Previous hospitalizations for asthma and recent foot injury/infection. No prior surgeries.

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.

Supervisor at mid-American copy and ship since high school. Hangs out at bars and clubs on free time. The patient is single with no kids Currently non-sexually active for two years. Her relationships are heterosexual. When dating she is monogamous. She has had 3 partners in her lifetime. Non-smoker \ occasional drinker. With History of marijuana us, but denies further drug or marijuana use. The Patient is involved in her Baptist church. They provide support and community for each other. The patient helps at events throughout the week. The patient is currently pursuing her bachelor’s in accounting. Patient uses seat belts occasionally and has working smoke detectors in house.

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.

Denies family hx of migraine, seizures, Parkinson’s disease, Alzheimer’s disease Father suffered from Diabetes II, hypertension, and hyperlipidemia. Her Father is deceased. Mother is living has hyperlipidemia and hypertension. Patient has one 23-year-old brother with no diagnosed health issues. She believes he is obese. One younger sister with asthma and no further health issues. Only living grandmother from paternal side “has issues” but not specified. Paternal grandfather also has unspecified issues and is deceased. maternal grandparents had high blood pressure and hyperlipidemia both are deceased.

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. Constitutional Skin HEENT If patient denies all symptoms for this system, check here: ☒ If patient denies all If patient denies all symptoms for this system, symptoms for this check here: ☒ system, check here: ☒ ☐Itching Click or tap ☐Diplopia Click or tap ☐Fatigue Click or tap here ☐Earache Click or tap here ☐Hoarseness Click or tap here to enter text. here to enter text. here to enter text. to enter text. to enter text. ☐Weakness Click or tap ☐Rashes Click or tap ☐Eye Pain Click or tap ☐Tinnitus Click or tap here ☐Oral Ulcers Click or tap here here to enter text. here to enter text. here to enter text. to enter text. to enter text. ☐Fever/Chills Click or tap ☐Nail Changes Click ☐Eye redness Click or ☐Epistaxis Click or tap ☐Sore Throat Click or tap here here to enter text. or tap here to enter tap here to enter text. here to enter text. to enter text. text. ☐Weight Gain Click or tap ☒Vision changes right ☐Vertigo Click or tap here ☐Congestion Click or tap here ☐Skin Color Changes here to enter text. eye 20/40 prior to car to enter text. to enter text. ☐Weight Loss Click or tap ☐Hearing Changes Click ☐Rhinorrhea Click or tap here Click or tap here to crash with blurry vision enter text. ☒Photophobia denies but or tap here to enter text. here to enter text. to enter text. headaches occur hourly ☐Trouble Sleeping Click or ☐Other: ☐Other: tap here to enter text. Click or tap here to Click or tap here to enter text. during the day.

☐Night Sweats Click or tap enter text. ☐Eye discharge Click or here to enter text. tap here to enter text. ☐Other: Click or tap here to enter text. Neuro Cardiac and Peripheral Vascular Respiratory If patient denies all symptoms for this system, check here: ☒ If patient denies all symptoms If patient denies all symptoms for this for this system, check here: system, check here: ☒ ☐ ☐Syncope or ☐Palpitations Click or tap ☐Chest pain Click or tap here to enter ☐Cough Click or tap here to enter Lightheadedness Click or tap text. here to enter text. text. ☐SOB Click or tap here to enter text. ☐Faintness Click or tap here here to enter text. ☐Hemoptysis Click or tap here to ☒Headache post car accident ☐Exercise Intolerance Click or tap here to enter text. enter text. non- cluster, cyclic or sharp ☐Claudications Click or tap to enter text. ☐Dyspnea Click or tap here to enter here to enter text. ☐Numbness Click or tap here ☐Orthopnea Click or tap here to enter text. to enter text. text. ☐PND Click or tap here to ☐Wheezing Click or tap here to enter ☐Tingling Click or tap here to ☐Edema Click or tap here to enter text. enter text. text. enter text. ☐Murmurs Click or tap here to enter ☐Other: Click or tap here to ☐Pain on Inspiration Click or tap here enter text. ☐Sensation Changes text. to enter text. ☐Sputum Production ☐Speech Deficits Click or tap here to enter text. ☒Other: denies HX of migraines, seizures, stroke ☐Other: Click or tap here to enter text.

MSK If patient denies all symptoms for this system, check here: ☐

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: ☒

☒Pain in neck 3/10 ☒Stiffness in neck with soreness ☐Crepitus Click or tap here to enter text. ☐Swelling Click or tap here to enter

☐Nausea/Vomiting Click or tap here to enter text. ☐Dysphasia Click or tap here to enter text. ☐Diarrhea Click or tap here to enter

☐Urgency Click or tap here to enter text. ☐Dysuria Click or tap here to enter text. ☐Burning Click or tap here to

☐Stress Click or tap here to enter text. ☐Anxiety Click or tap here to enter text. ☐Depression Click or tap here

text. ☐Limited ROM ☐Redness Click or tap here to enter text. ☐Misalignment Click or tap here to enter text. ☒Other: ROM limited due to pain and immobility alleviates pain to the neck.

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:

GYN If patient denies all symptoms for this system, check here: ☒ ☐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.

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.

Hematology/Lymphatics If patient denies all symptoms for this system, check here: ☒ ☐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.

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.

Endocrine If patient denies all symptoms for this system, check here: ☐ ☐ 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 random blood glucose level is 117 ☐ Other Click or tap here to enter text.

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.

Body System

Positive Findings

Negative Findings

General Head ache and neck pain

Headache and neck pain

Click or tap here to enter text.

Warm, dry, elastic, and smooth

Click or tap here to enter text.

No rhinorrhea or congestion

Click or tap here to enter text.

No wheezing or reports of sob.

Skin

HEENT

Respiratory

Neuro Headache post car accident. Cranial Nerve: (II) visual acuity right eye & cotton wool bodies to right fundus visualized through the ophthalmoscope Sensation: decreased sensation to bilateral feet.

Oriented to person, place, and time. Appropriate abstract thinking, attention span, comprehension, general knowledge, judgment, remote and immediate memory, new learning ability, vocabulary with clear speech Cranial Nerves: (I) able to discriminate various smells (II, III, IV, VI) Visual acuity 20/20 left eye w/ normal visual fields in all quadrants. PERRLA with extraocular movements intact without nystagmus. (V) Facial sensation sensitive to dull, sharp, & soft stimulus bilaterally. (VII) Facial expression & skull symmetric bilaterally. (VIII) normal Weber & Rinne test (IX, X) intact gag reflex, with palate & uvula midline & symmetric (XI) Shoulder shrug equal b/l with strength 5/5 (XII) tongue symmetric and movement. Reflexes: triceps, biceps, brachioradialis, patellar, & Achilles 2/4 bilaterally. Cerebellar: smooth & accurate finger to nose and heel to shin tests bilaterally Rapid alternating hand movements

Problem List 1. Headaches w/ increased frequency 2. Neck pain w/ stiffness and soreness 3. right eye visually deficient 20/40 4. cotton wool bodies to the right fundus 5. Click or tap here to enter text.

6. Click or tap here to enter text. 7. Click or tap here to enter text. 8. Click or tap here to enter text. 9. Click or tap here to enter text. 10. Click or tap here to enter text.

11. Click or tap here to enter text. 12. Click or tap here to enter text. 13. Click or tap here to enter text. 14. 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. Diagnosis ICD-10 Code Pertinent Findings Positives: neck pain of 3/10 in severity worsening with S13.4XXA Sprain of ligaments of cervical spine, initial encounter. spine, initial encounter Concussion with ought loss of consciousness initial encounter.

movement starting two days s/p recent motor vehicle accident. Negatives: cranial nerve XI 5/5 : full ROM against Gravity & resistance. S13.OXOA

G44.319 Acute Post Traumatic Headache

Positives: acute headaches during the day with acute neck soreness & stiffness after recent Motor vehicle accident. Cotton wooly bodies may be seen after head trauma. Negatives: balance & gate steady and continuous, intact remote and immediate memory, appropriate concentration. Positives: dull headache specific to the crown and posterior head. Occurs every day since day two of a recent motor vehicle

car accident (Tanaka et al., 2018). Pain lasting 1-2 hours. Negatives: nausea, insomnia, memory problems, diplopia (American Migraine Foundation, 2018). X-ray

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.

Diagnostics: List tests you will order this visit Test X- ray of the neck

Rationale/Citation

According to the Imaging

conditions for Suspected Spine Trauma from the American College of Radiology Criteria, Tina meets the low risk factor of simple rear-end-motor vehicle collision and delayed onset neck pain with complaints on limited neck movement due to pain qualifies for diagnostic

imaging (Blanpied et al., 2017). Although during the neurological assessment, Tina show full ROM of the neck against gravity and resistance for cranial nerve XI, her initial complaint was regarding the limited ROM of her neck due to pain. Therefore,

clinically it is acceptable to order a x-ray of the neck to rule out any trauma. A CT of the head was considered during this process as it is essential to first rule out traumatic brain or spine injury (Ontario Neurotrauma Foundation, 2018). A CT of the head is

not indicated at this time because she does not meet the five Canadian CT Head Rule of GCS...