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Neuro SOAP NOTE 2 1 Running head: NEURO-RELATED CC 9 Running head: NEURO-RELATED CC Neuro-Related CC Student’s Name Institution Affiliation Course Name Professor’s Name Date Neuro-Related CC CC: My muscles are weak History of Present Illness The patient is a female adult aged 38 years old. She was reported with a three-month history of arthritis after experiencing muscle weakness and mild headache. She started experiencing the symptoms in the past five-months months (May 2021). The patient at that time had hard joint pain in the knees, legs, and arms. After running the diagnosis, she was found to be suffering from Arthritis. To alleviate the symptoms, she was advised to take a short course of corticosteroids. Later on, the patient was kept on methotrexate, but the medication was not effective after a month, and she explained her concerns to the physician and was asked to stop taking the medication. The symptoms experienced by the client began worsening after two months when she stopped taking the methotrexate medication. She could vomit, experience nausea more often, sleepless nights, worsening headaches, and weak. She reported that loss of consciousness was experienced. Headaches were worse, making her not stand for about three to four hours, and occurred twice a week. The patient reported that she had experienced an increase in the frequency of headaches that could last the whole day in the past month. With the increased headache, she reported that she could lie down, unable to stand. The patient is currently experiencing unbearable pain concurrently in the knee joints and arms, which leads to swollen and hot joints. She reported that she was experiencing dry mouth that made it difficult for her to Swallow food and felt a burning sensation in her eyes. During the night, she could experience excess sweating even if it was cold and mild fever, which made her unable to sleep comfortably and could stay awake most of the night. She reported that lack of sleep during the night affected her day since she could mostly doze off while at work. While she was at some two days ago, the patient felt a constant and unbearable headache that left her to sit in one position for about two hours. Later on, she asked for permission and left for the day. No appetite to eat any food, and she tried to swallow. She could vomit after some hours. She visited the toilet normally, but once in a day, the stool and urine appeared to be expected. Due to lack of eating and vomiting after eating a small portion, her body was weaker; hence, she could not even take out of her bedroom without being supported. Her brother and a cousin helped the patient who arrived in the hospital after not eating for two consecutive days. While at the hospital, nurses discovered that patient had rashes on her face and extended to her nose and eyelids. Upon inquiring from the patient for how long she had the rashes, she was not aware of the rashes preset on her face. The rashes were reported to increase each day the patient was in the hospital. Examination revealed she had lost 30 pounds of weight, and a deceases was seen in her muscle mass. Due to a lack of appetite, the patient experienced satiety and nausea. Her temperature was a bit high, and no loss of sensation was reported. Depression, mood, and frustration were reported since the patient could not carry on her daily routines or get time to socialize with her peers. Past Medical History: Hypertension, headache, and loss of appetite. Gastric hernia and ulcers. Medications recommended Tramadol 50mg 2 tablets a day, Zoloft 100 mg Ibuprofen 500 mg three times a day. Allergies Due to the patient experiencing ulcer symptoms, she was asked to avoid taking foods that contain acidity, such as red beans, and advised to take milk in more frequently. To remove the gastric hernia, she underwent a minor surgery that was eight years ago. Social history The patient completed her high and progressed to do her career course in Computer Science, she graduated with first-class honor. Upon her completion, she got a job opportunity at Microsoft and still working in the company. The patient currently lives with her cousin after the husband and children relocated to another state where the husband got green pasture and she is yet to join him. The patient career involves Information Technology mainly software development. Family History She is a married woman with three children, two girls, and one boy. She reported being taking minimal alcohol during functions. Her mother is alive and doing farming in their rural home while her dad died last year, 2020, due to the Covid 19 pandemic. Review of systems Her Skin showed some rushes on the face, but the rest of the skin was normal. The skin looked dry, and skin hair was intact, easy bruising, and the skin showed signs of discoloration. The hematopoietic showed she experienced fatigue, headaches most of the time, non-fainting, and tinnitus negative. From the face and head, she appeared to be ok since it was had not swollen. She could hear normally but had a few discharges. The eye site was normal. No sign of coughing, wheezing, and chest pain was experienced. General Physical Examination Physical findings showed that the patient blood pressure was 110/95, the temperature was 36.7C, Respiratory 25and oxygen saturation 92\%. The patient was able to recall her memories and past events and was able to speak in a usual manner and appropriately. Neurologic Examination Mental Status The patient is of sound mind and communicate well Three differential diagnoses 9th June 2021 Autoimmune Negative Rheumatoid Positive for HLA class 2 Positive double-stranded DNA antibody (normal > 300 Positive SS-A Hematologic Normal Rbc ( 5.32) Low hemoglobin ( 10.9) Hematocrit normal ( 42.4) Infections Hepatitis was negative (presence of B surface and hepatitis C), positive STI (syphilis presence), Urine positive ( odor smell ), and parvovirus showed negative 10th July 2021 Hematologic Elevated creatinine was normal at 119 Normal hemoglobin 14.2 Deceased platelets 130 6th August 2021 Scan Head scan showed normality Assessment In summary, the 38-year-old female patient had a history of arthritis, and she didnt have a family history on the same. She presented herself at the facilities after a five-month history of headache, joint pain in the knee and hand, weak and loss of appetite. She has had unbearable headaches, sweating at night, weaker, nausea, and a sleepless night in the last two months. In the past week, she reported having burning eyes and experienced dry mouth; the test result showed low hemoglobin of 10.9 and normal red blood cells. (Risso, 2021). Plan Problem 1 Systemic Lupus Erythematosus (SLE) could be a condition that the patient was suffering from. The SLE can account for low hemoglobin, but it doesnt explain the patients burning eyes and dry mouth. The doctors rashes on the patient face were not something to worry about since there were only seen in the pre-auricular area during the examination. The plan for this problem is to keep close to how the patients kidney functions. Currently, no appropriate treatment for acute exacerbation has been found. Problem 2 headache Since the head scan showed no sign of abnormality in the patient, they can advise her to take Naprosyn 400mg for about two months. In case the medication is not effective, the doctor can suggest narcotic analgesia. The patient has a history of depression, a tricyclic antidepressant that works effectively in her case. Problem 3 Siogrens syndrome assessment ` The Sjogrens syndrome assessment in most cases is associated with arthritis. An average estimation of 20- 32\% is witnessed in those that are suffering from arthritis. The results during a laboratory showed a Positive SS-A, the scan showed no sign of abnormality, the possibility of dry eyes and mouth was the availability of Sjogrens syndrome or trigeminal neuralgia. Research shows that patients who show signs of SS have abnormal counts in the cell line, while cytopenia patients have more than one cell line. We could rule out anemia to be the leading cause of muscle weakness and headache. (Suzuki et al., 2020) The plan in this scenario was to help find out if the eye dryness was due to Schirmer. Medication that can be considered in this scenario could be hydroxychloroquine and immunosuppressant; this medication will help reduce joint pain. Patient white blood cells and red blood cells should get monitored to ensure they are all normal. Reference Risso, M. (2021). Sleep Disorders in Patients with Psoriatic Arthritis. SOJ Complementary And Emergency Medicine, 1(2). https://doi.org/10.53902/sojcem.2021.01.000506 Suzuki, E., Ichimura, T., Kimura, S., Kanno, T., & Migita, K. (2020). Primary Sjögren’s Syndrome Accompanied by Clinical Features of TAFRO Syndrome. Case Reports In Rheumatology, 2020, 1-7. doi: 10.1155/2020/8872774 Create a neuro-related CC. Create an ID, CC, HPI, ROS, V/S, physical findings, and assessment with at least 3 differential diagnoses, a final diagnosis, and treatment plan in a full SOAP note format. Use a neuro related CC that a patient would present with in a primary care setting (i.e. no emergency room or ICU type complaints). Examples: regular headaches, migraines, dizziness, dementia or memory loss, weakness, neuropathy, etc.. Include at least two references for your diagnostic and treatment plan. They should be recent (in the last 5-10 years) and peer-reviewed. Use APA title page, citation, and references. Ensure the treatment plan includes all components (diagnostic plan, therapeutic plan, education plan, and follow up).  The ROS and physical exam in your document should be written up as they would be for a problem focused visit. The neurological part of the physical exam write up should be a comprehensive write up, including everything you assessed in your recording. Note (Important information) when writing the History of present illness HPI) use this OLDCARTs Onset, Location, Duration, Characteristics, Aggravating facting, Relieving factor and Treatment and severity