Assignment: SOAP Note for Tina Jones on Neurologic Assessment

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Patient Information:

J, a 28-year-old, African American Female with insurance.

CC (chief complaint): T. J states that the reason for seeking the care is that she got into a little fender bender and has been experiencing “headaches with sore neck.”

HPI: T.J came to the hospital complaining of a headache and neck stiffness acquired from a minor fender bender. A week ago, and as a restrained passenger, she was involved in an accident, which occurred in a parking lot. She reports that the speed was 5-10 mph. T.J. and the driver refused to seek emergency care as they felt fine. However, two days later, T.J begun having bilateral temporal ache alongside neck pain. She further reports that she has a feeling that her neck might be swollen. She lost consciousness in the accident; however, denies any alterations in the consciousness since then.

Onset: 2 days after the accident

Location: Head and neck

Duration: Approximately 1 -2 hours every day for the last five days.

Characteristics: Dull ache that radiates to the back of the head.

Aggravating Factors: Worsens with movement.

Relieving Factors: She denies trying heat or ice therapy for comfort.

Severity: 4 out of 10 on a pain scale

Treatment: 650 mg Tylenol for the pain

Current Medications: 650mg Tylenol Over the Counter, PO every 4-6 hours, for managing her headache for the past two days; Advil 600mg orally as needed to manage her cramps; Albuterol (Proventil) MDI 90 mcg/spray, which she takes two puffs after every 4 hours, for her breathing difficulties; Flovent MDI 110 mcg/spray which she administers two puffs after every 12 hours.

Allergies: She is allergic to PCN. She claims that it causes rash or hives on her skin.

PMHx: Asthma; Uncontrolled diabetes type 2 as she has not been taking any medication; Never had any surgery in the past.

Soc Hx: T.J is currently single. She works at Mid-American Copy & Ship as the supervisor. She denies using tobacco or any other illicit drugs. She, however, claims that she has been taking alcohol occasionally.

Fam Hx: No history of migraine, seizures, Parkinson’s disease or Alzheimer’s disease

ROS:

CONSTITUTIONAL: Denies weight changes, generalized body weakness, fever, chills, fatigue, sweats or night sweats.

HEENT: Head: Denies current headache. Denies history of trauma before the current incident. Eyes: denies wearing corrective lenses; however, complains of worsening vision in the past few years. Complains of having blurry vision especially after studying for a long time. No increased itching or tearing. Ears: No hearing loss, tinnitus, vertigo, earache or discharge. Nose/Sinuses: No stuffiness, rhinorrhea, itching, sneezing, previous allergy, sinus pressure or epistaxis.

SKIN: No itching or skin rash.

CARDIOVASCULAR: No problems with chest pain or palpitation, or funny feeling of the heart skipping beats.

RESPIRATORY: No shortness of breath, cough, crackles, wheezes, or sputum.

GASTROINTESTINAL: No nausea, vomiting or abdominal pain.

GENITOURINARY: No pain upon urination, vaginal itching, excessive urination or hot flashes. No foul urine odor.

MUSCULOSKELETAL: No general muscle weakness, difficulties with a range of motion, pain, swelling or joint instability. Complains of stiffness and pain on the sides and back of her neck, which worsens with movement — no back pain or gait.

HEMATOLOGIC: No signs of anemia, bruises or bleeding.

LYMPHATICS: No splenomegaly or any other enlargement of lymph nodes.

PSYCHIATRIC: No confusion, memory issues, depression, anxiety, mood instability or sleeping problems. Speech clear and appropriate.

NEUROLOGICAL: No loss of sensation, tingling, numbness, tremors, paralysis, weakness, fainting, seizure, or blackouts. No bladder or bowel dysfunction. No changes in sleeping patterns, concentration, appetite or coordination, appetite.

ALLERGIES: allergic to penicillin. Presents as rashes or skin hives.

Physical exam:

Vital Signs: BP 139/87; T 98.9; P 82. RR 16/min; PO 99% on room air; Wt. 88 kg; BMI 30.5; Blood glucose 117.

CONSTITUTIONAL: She is alert and well oriented. Maintains eye contact. No acute distress. Speech is clear and appropriate.

HEENT: Head: atraumatic and normocephalic. Eyes: bilateral with equal distribution of hair. The left eye vision is 20/20 while that of the right eye is 20/40. Sharp disc margins revealed by the left fundoscopic exam, with no hemorrhages — mild retinopathic changes on the right side. The pupils are round, equal and bilaterally reactive to light. Normal convergence. Ears: normal bilateral hearing. Neck: full motion against resistance. Throat: Intact gag reflex. The tongue has normal symmetry with no abnormalities.

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SKIN: No signs of skin rash or itching.

CARDIOVASCULAR: Regular heart sounds and rhythm. S3 and S4 are absent but S1 and S2 present. No heart murmurs noted. No carotid bruits heard.

RESPIRATORY: Both lungs are excellent, with no signs of wheezing or crackles. Breathes with no difficulties. Normal lung sounds.

GASTROINTESTINAL: Abdominal skin is good, with no pain on palpation.

GENITOURINARY: Normal genitally noted with no signs of herniation.

MUSCULOSKELETAL: Bilateral lower and upper extremity with equal DTRs and 2+ bilaterally. Smooth and accurate point to point movement from heel to shin and finger to nose. The upper extremities exhibit rapid alternating movements which are intact bilaterally. A steady gait with continuously symmetric steps. Intact sensation to bilateral lower and upper extremities. The sense of positioning of the extremities is intact.

PSYCHOLOGICAL: Maintains good contact while answering all the questions. She is very alert, calm, and responsive through all the physical examination. Does not seem stressed or anxious.

NEUROLOGICAL: Intact sense of smell and symmetric. Symmetric ability to shrug shoulders. Intact facial sensation with symmetric facial features. Intact stereognosis and graphesthesia bilaterally.

Diagnostic results: Acute post-traumatic headache as a result of a low-speed Motor Vehicle Accident in which the patient was a restrained passenger.

Assignment: SOAP Note for Tina Jones on Neurologic Assessment

Differential Diagnoses

Acute post-traumatic headache (ICD-10 Code) related to MVA: Positive for headache attributed to the head injury (Marshall et al., 2015). Negative for atypical facial pain, migraines, and trigeminal neuralgia.
Tension-type headache (ICD-10 Code) related to neck strain from MVA: Positive dull headache, pain on the back and sides of the neck and neck stiffness. Negative for sensation of tightness across the forehead and tenderness on the scalp, shoulder, and neck (Marshall et al., 2015).
Unspecified injury of the neck, initial encounter (ICD-10 Code) related to MVA: positive for a persistent headache, stiff neck, and neck pain on the sides and the back (Marshall et al., 2015). Negative for trigeminal neuralgia.

Diagnostics:

Cervical X-rays
CT scan
MRI
EEG

Rx:

Start the patient on ibuprofen 800mg PO three times a day with food for five days to manage the pain and fever.
Continue 500-1000 mg Tylenol OTC PO, after every 4 to 6 hours to manage the pain.
Adjunct therapy with topical ice or heat, at the patient’s preference, either three or four times a day.

Education:

Encourage the patient to take medications strictly as prescribed by the physician.
Advise the patient to observe the symptoms of her condition and alert the doctor in case of any severity or increase in the frequency of the headache.
Educate the patient to apply nonpharmacological measures in managing her condition such as ice application, cool presses to the head, scalp, neck or face, moist heat application, quiet atmosphere and darkened room (Hugentobler, Vegh, Janiszewski, & Quatman-Yates, 2015).
Encourage the patient to adopt mild stretches to help in relieving the upper back and neck stiffness.
Encourage the patient to avoid unnecessary movement that could worsen the symptoms of her condition (Lennon, Ramdharry, & Verheyden, 2018).

Referral/Consults: None for the current patient’s visit.

Follow up:

Explain to Ms. Jones when emergency care is required in instances such as worsening of the headache, hearing problems, changes in vision, loss of consciousness, increased episodes of nausea and vomiting that is accompanied by extreme headache, tingling, numbness, or paralysis of new onset (Lin et., 2015).
Advise the patient to call the hospital after every two weeks for review of her symptoms and alteration of the treatment plan with better interventions.
Visit the clinic after 5 to 7 days for evaluation and assessment of the presenting illness and monitoring the effectiveness of the prescribed medication.

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.