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neuro soap note 2 different copies 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 NEURO SOAP NOTE 2 NEURO SOAP NOTE 2 RUNNINGHEAD: NEURO SOAP NOT 1 Neurological Exam Soap Note Week United States University: MSN 572 August 9, 2021 This study resource was shared via CourseHero.com ID : M.J. DOB 03/18/1978, 43-year-old married Black male presents to the office today accompanied by his wife. Subjective Chief complaint “ My face feels like it’s numb.” History of Present Illness M.J is a43-year-old black male born and raised in California, who presents to the clinic today with complaints of his face “feels like it’s numb.” His symptoms began two days ago at work and has been constant, with the right side of his face feeling more numb than the left side. M.J has worked for the Department of Motor Vehicles for the past 15 years. His schedule is Monday thru Friday, 9am to 5pm weekly. He states that he has been feeling extremely overwhelmed at work related to an increased workload and unrealistic expectations from his managers. He states that he feels his managers are “out to fire him”, and this is the cause of his distress. Primary Medical History Allergies : No known Drug Allergies PMH : No past medical history. No history of viral infection, hypertension, diabetes, or migraines. Last doctor’s visit 1 year ago for annual physical exam. Surgical History : Drainage of rectal abscess 10 years ago. Immunizations : Childhood immunizations up-to-date to the best of his knowledge. Has never received the flu vaccine. Received Pfizer Covid vaccine 3/2021. Family history : Mother is in her early 50s and is overweight with no known medical conditions. Father is alive in his late 50’s and has hypertension and high cholesterol. He is unaware of any medical conditions to his maternal grandparents, who are alive and separated. His paternal This study resource was shared via CourseHero.com Social History grandfather passed away ten years ago from colon cancer and his paternal grandmother is alive in her 70’s and has a history of COPD. He has one younger brother, age 38, with no known medical history. His three school-age children are healthy with no medical history. Medications : Does not take any prescription or OTC medications. Marital history: Married for 13 years Occupation: State employee for 15 years at the Department of Motor Vehicles. Diet/exercise: Drinks an adequate amount of water throughout the day and eats about two big meals with a snack. His usual meal consists of take-out food for lunch or leftover dinner with rice, vegetables, and protein. He may eat oatmeal at work for breakfast. Safety: M.J is a registered gun owner and keeps his firearm in a locked safe, away from his family. Wears a helmet when riding his motorcycle 100\% of the time. Wears a seatbelt 100\% of Sexual/Reproductive: In a monogamous relationship. Drug use: Occasionally uses marijuana once or twice a month, usually when he’s with friends. Last use was 3 weeks ago. First use as a teen. Alcohol use: Denies use of alcohol. Tobacco: Denies smoking cigarettes, vaping, or e-cigs. Sleep: Sleeps 6-8 hours a night. Denies waking up throughout the night. Review of Systems Constitutional : Denies pain, fever, and chills. Denies any weight changes. Integumentary Denies any rashes, bruises, open wounds, lesions, or cuts to skin. : This study resource was shared via CourseHero.com Spiritual: Christian the time. urination. HEENT : Patient wears prescription glasses, denies any vision changes, blurriness or diplopia. Denies sore throat, dysphagia, problems smelling. Reports dry eyes for past two days. Reports increased sensitivity to loud noise such as the vacuum and music. Reports discomfort located in the right postauricular area lasting for 30 minutes, beginning at work. Patient stated he drank more water and eventually it went away. Pain level was described as 5/10. No history of chronic headaches. Reports changes in taste, such as food tasting “more bland than usual”. Pulmonary : Denies shortness of breath, dyspnea, cough. Cardiovascular : Denies chest pain or abnormal swelling to his extremities. Gastrointestinal Denies nausea, vomiting, diarrhea, or constipation. : Genitourinary : Denies any pain, bleeding, burning, frequency, retention, or hesitancy with Neurological: Denies any recent falls. Denies dizziness, seizures, light-headedness. Denies any trauma. Denies any numbness to bilateral hands, feet, arms, legs, and toes. Reports numbness to right side of face and lip area, does not include the orbital area. Musculoskeletal : Denies any weakness to upper and lower extremities. Psychological : Denies feelings of hopelessness, despair, intent to hurt self or others. Verbalizes feelings of frustration and being upset due to work related issues. Sleeps 6-7 hours a night, and does not awaken throughout the night. Allergy/Immunology : Denies any current or previous hematologic disorders. Denies any current or previous systemic disorders. Denies allergies to food, pets, environmental, and medications. Denies any abnormal bleeding or bruising. Objective This study resource was shared via CourseHero.com gland. noted. Vital Signs : BP: 138/65. Temp: 98.9 F Pulse: 85 RR:18 O2 sat: 100\% RA. Current weight and height: 6’0, 180 lbs., BMI: 24.4, normal. Integumentary: General skin color is normal for ethnicity. No skin rashes, lesions, open wounds, or scars noted. Skin turgor is normal. Lymphatic : No swelling or tenderness to the bilateral occipital, temporal, mandibular, submental, preauricular or tonsillar lymph nodes. Swelling and tenderness noted to right post auricular area. Head : Head contour and shape is normal with no visible deformities or trauma noted. No depressions, lesions, rashes or hematomas noted upon palpation. No tenderness or swelling palpated to frontal or maxillary sinuses. Ears: No drainage noted to bilateral ears. No redness or swelling noted bilaterally to auditory canal. Tympanic membrane is pearly gray. Five o’clock cone of light to right ear. Seven o’clock cone of light cone to left ear present. Whisper test is negative, patient is able to repeat whispered word to bilateral ears. Eyes: Patient wears prescription glasses. PERRLA intact. CN II, III, IV, VI intact. Confrontation is positive OD, OS. Negative for nystagmus. Sclera is white. Red reflex intact. Disc to cup ratio is 3:1, and disc is sharp to OD, OS. Conjunctiva is pink, dryness noted to OS, OD. Nose: Nasal septum midline. No postnasal drip, drainage, redness, lacerations or swelling noted to nasal canal/mucosa. Mouth : No redness, swelling, bleeding noted to oral mucosa. Oral mucosa is moist and normal color for ethnicity. CN X & IX intact. No swelling or inflammation noted to posterior pharynx, tonsils and soft palate. Tongue is midline. Throat Trachea is symmetrical with no deviation. No swelling or tenderness of the thyroid : This study resource was shared via CourseHero.com Pulmonary/Thorax : Respirations are even and unlabored. No signs of dyspnea. Posterior, lateral, and anterior lung sounds are clear with no adventitious sounds. No use of accessory muscles Gastrointestinal: Abdomen is soft, flat, nontender, no visible pulsations noted. Last BM today- normal consistency and frequency for patient. Genitourinary: Bladder is soft, nontender. Musculoskeletal: ROM and motor strength to upper and lower extremities intact, 5+. Cardiovascular : S1 and S2 present. No thrills palpated. No bruits or murmurs upon auscultation. Rate and rhythm are regular at 89 beats/minute. No swelling noted to upper and lower extremities. Capillary refill to fingernails and toenails 3+. No clubbing or cyanosis noted to fingers and toes. Neurological: Speech is clear and concise. Alert and oriented x4. CN I (olfactory) intact, patient is able to smell appropriately in both nares. CN II (optic) intact, vision is 20/20 with prescription eyeglasses in place. CN III (oculomotor) intact, patient is able to , IV (trochlear), V (trigeminal), VI (abducens), VIII (acoustic), IX (glossopharyngeal), XII (hypoglossal) intact. DTR to bilateral biceps, triceps, patellar, and Achilles 2+. Weakness noted to CN VII (facial). Smile is unequal on the right side. Difficulty raising right eyebrow. No facial drooping noted. Assessment Differential Diagnosis: 1. Bell Palsy ICD G51.0- CN VII weakness noted. Impaired ability to raise ipsilateral eyebrow, impaired ability to smile, tenderness to right postauricular lymph node area, decreased tearing/dryness to eyes, changes in taste (Domino, 2022). This study resource was shared via CourseHero.com   2. Acute Stroke ICD I63.9- Complaints of numbness and tingling to right side of face. No facial drooping noted. Romberg and pronator drift negative. Speech is clear and coherent. No changes in vision. No changes in gait or balance. 3. Guillen-Barre Syndrome G61.0- Cranial nerve VII weakness to the right side of the face and complaints of paresthesia. No progressive limb weakness. CN V motor and sensory function intact. ROM and motor strength to upper and lower extremities intact, 5+. Steady gait, no c/o dizziness. DTR of biceps, triceps, patellar, Achilles 2+. No recent flu vaccinations, GI, or respiratory infections. Vital signs within normal limits. Final Diagnosis: Bell Palsy- inflammation of CN VII triggered by event related stressor. Plan Diagnostic Labs & Studies: CBC, CRP/ESR HIV test, rapid plasma reagin (RPR) test. Lyme serology: ELISA or IFA, Western blot for IgM, IgG for Borrelia burgdorferi Titers for Varicella zoster virus, rubella, cytomegalovirus, hepatitis A, B, C. Electromyography (EMG) if paralysis lasts more than one week. Facial/skull radiography, CT scan or MRI to rule out stroke, facial fracture, tumor, or neoplasms. (Domino, 2022) Treatment: Prednisone 60mg oral daily for the first 5 days. Then, taper dose by 10mg/day for the next five days. Valacyclovir 1,000 mg three times daily for seven days. Ibuprofen 600 mg oral every 6 hours as needed for moderate-severe pain 5-10. May alternate with acetaminophen for breakthrough pain 1,000 mg oral every 6 hours as needed (Domino, 2022) This study resource was shared via CourseHero.com       weeks. Patient teaching : May use cold or heat packs for 10-20 minutes at a time, four times a day for pain relief. Make sure not to apply cold pack directly to skin, rather wrap it in a towel first to prevent frost bite. Wear eye protection during the day. Taping the affected eye at night and using lubricating eyedrops or ointment will keep the eyes from drying out and remaining moist. Take analgesics as needed. Referrals : Refer to an ENT or ophthalmology specialist if ocular complications arise. A referral to a neurologist may be warranted if symptoms worsen or do not resolve adequately after four Follow up : Follow up with PCP in four weeks, or sooner, if symptoms worsen or do not resolve. Report any new changes to vision, trouble walking, or headaches. References Cash, J. C., & Glass, C. A. (Eds.). (2017). Family Practice Guidelines. New York; Springer Publishing Company. Domino, F.J., Baldor, R.A., Berry, K., Golding, J., & Stephens, M.B. (2022). The 5-minute clinical consult 2022. Lippincott Williams & Wilkins. This study resource was shared via CourseHero.com Powered by TCPDF (www.tcpdf.org) This study source was downloaded by 100000784384444 from CourseHero.com on 10-06-2021 22:47:35 GMT -05:00 https://www.coursehero.com/file/103073583/Bernadette-Bohol-NEURO-SOAP1-Copydocx/ This study source was downloaded by 100000784384444 from CourseHero.com on 10-06-2021 22:47:35 GMT -05:00 https://www.coursehero.com/file/103073583/Bernadette-Bohol-NEURO-SOAP1-Copydocx/ This study source was downloaded by 100000784384444 from CourseHero.com on 10-06-2021 22:47:35 GMT -05:00 https://www.coursehero.com/file/103073583/Bernadette-Bohol-NEURO-SOAP1-Copydocx/ Sample Write-Ups Sample Neurological H&P CC: The patient is a 50-year-old right-handed woman with a history of chronic headaches who complains of acute onset of double vision and right eyelid droopiness three days ago. History of present illness: Mrs. Smith states that on Sunday evening (7/14/03) about 20 minutes after sitting down to work at her computer, she developed blurred vision, which she describes as the words on the computer looking fuzzy and seeming to run into each other. When she looked up at the clock on the wall, she had a hard time making out the numbers. At the same time, she also noted a strange sensation in her right eyelid. She went to bed and upon awakening the following morning, she was unable to open her right eye. When she lifted the right eyelid with her fingers, she had double vision with the objects appearing side by side. The double vision was most prominent when she looked to the left, but was also present when she looked straight ahead, up, down, and to the right, and went away when she closed either of her eyes. She also noted that she had pain in both of her eyes that increased if she moved her eyes around, especially on looking to the left. She was seen in the Alton Memorial Hospital ER and subsequently transferred to BJH by ambulance. Mrs. Smith also notes that for the past two to three weeks, she has been having intermittent pounding bifrontal headaches that worsen with straining, such as when coughing or having a bowel movement. The headaches are not positional and are not worse at any particular time of day. She rates the pain as 7 or 8 on a scale of 1 to 10, with 10 being the worst possible headache. The pain lessened somewhat when she took Vicodin that she had lying around. She denies associated nausea, vomiting, photophobia, loss of vision, seeing flashing lights or zigzag lines, numbness, weakness, language difficulties, and gait abnormalities. Her recent headaches differ from her “typical migraines,” which have occurred about 4-6 times per year since she was a teenager and consist of seeing shimmering white stars move horizontally across her vision for a couple minutes followed by a pounding headache behind one or the other eye, photophobia, phonophobia, and nausea and vomiting lasting several hours to two days. She has never taken anything for these headaches other than ibuprofen or Vicodin, both of which are partially effective. The last headache of that type was two months ago. Her visual symptoms have not changed since the initial presentation. She denies previous episodes of transient or permanent visual or neurologic changes. She denies head trauma, recent illness, fever, tinnitus or other neurologic symptoms. She is not aware of a change in her appearance, but her husband notes that her right eye seems to protrude; he thinks that this is a change in the last few days. Past medical history: 1. Migraine headaches, as described in HPI. 2. Depression. There is no history of diabetes or hypertension. Medications: Zoloft 50 mg daily, ibuprofen 600 mg a few times per week, and Vicodin a few times per week. Allergies: None. Social history: The patient lives with her husband and 16-year-old daughter in a 2-story single-family house and has worked as a medical receptionist for 25 years. She denies tobacco or illicit drug use and rarely drinks a glass of wine. Family history: Her mother had migraines and died at the age of 70 after a heart attack. Her maternal grandfather had a stroke at age 69. There is no other family history of stroke or vascular disease, but she has no information about her father’s side of the family. Review of systems: She states that she had an upper respiratory infection with rhinorrhea, congestion, sore throat, and cough about 6 weeks ago. She denies fever, chills, malaise, weight loss, neck stiffness, chest pain, dyspnea, abdominal pain, diarrhea, constipation, urinary symptoms, joint pain, or back pain. Neurologic complaints as per HPI. General physical examination: The patient is obese but well-appearing. Temperature is 37.6, blood pressure is 128/78, and pulse is 85. There is no tenderness over the scalp or neck and no bruits over the eyes or at the neck. There is no proptosis, lid swelling, conjunctival injection, or chemosis. Cardiac exam shows a regular rate and no murmur. Neurologic examination: Mental status: The patient is alert, attentive, and oriented. Speech is clear and fluent with good repetition, comprehension, and naming. She recalls 3/3 objects at 5 minutes. ranial nerves: CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Pupils are 4 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally. CN III, IV, VI: At primary gaze, there is no eye deviation. When the patient is looking to the left, the right eye does not adduct. When the patient is looking up, the right eye does not move up as well as the left. She develops horizontal diplopia in all directions of gaze especially when looking to the left. There is ptosis of the right eye. Convergence is impaired. CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact. CN VII: Face is symmetric with normal eye closure and smile. CN VII: Hearing is normal to rubbing fingers CN IX, X: Palate elevates symmetrically. Phonation is normal. CN XI: Head turning and shoulder shrug are intact CN XII: Tongue is midline with normal movements and no atrophy. Motor: There is no pronator drift of out-stretched arms. Muscle bulk and tone are normal. Strength is full bilaterally.   Deltoid Biceps Triceps Wrist extension Finger abduction Hip flexion Hip extension Knee flexion Knee extension Ankle flexion Ankle extension L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 Reflexes: Reflexes are 2+ and symmetric at the biceps, triceps, knees, and ankles. Plantar responses are flexor. Sensory: Light touch, pinprick, position sense, and vibration sense are intact in fingers and toes. Coordination: Rapid alternating movements and fine finger movements are intact. There is no dysmetria on finger-to-nose and heel-knee-shin. There are no abnormal or extraneous movements. Romberg is absent. Gait/Stance: Posture is normal. Gait is steady with normal steps, base, arm swing, and turning. Heel and toe walking are normal. Tandem gait is normal when the patient closes one of her eyes. Laboratory Data: (Record here all available lab data; circle any abnormal values). CT (non-contrast) 7/17: no abnormalities. Orbits not well seen. MRI 7/18: Multi-focal areas of increased signal on T2 and FLAIR in the deep white matter bilaterally. These range in size from 1 to 10 mm and do not enhance after administration of gadolinium. There are no signal abnormalities in the brain stem or in the corpus callosum. No abnormalities in orbits, sinuses, or venous structures. Assessment: In summary, the patient is a 50-year-old woman with longstanding headaches who has had an acute onset of pupil-sparing partial third nerve palsy on the right (involving levator palpabrae, superior rectus, and medial rectus) associated with a bifrontal headache. Because this is an isolated third nerve palsy without involvement of other cranial nerves or orbital abnormalities, the lesion is localized to the nerve itself, e.g. in the subarachnoid space. Ophthalmoplegic migraine remains a likely diagnosis given the history of migraine with aura, even though the current headache is different in character from her usual headaches and is not associated with visual aura, nausea/vomiting, or photophobia. However, other potentially serious causes of third nerve palsy must be excluded. If a third nerve palsy is due to a compressive lesion, the pupillary fibers will generally become involved within about one week of the onset of symptoms. So the fact that her pupil is normal in size and reactive to light weighs against the diagnosis of a compressive lesion such as an aneurysm or tumor, but does not eliminate the possibility. The MRI does not show evidence of a mass lesion, but an aneurysm cannot be completely excluded without an angiogram. Another potentially serious cause of the third nerve palsy is meningitis. The patient is afebrile, has no meningeal signs, is well-appearing, and has been stable over three days, making bacterial meningitis highly unlikely, but atypical meningitis including fungal, Lyme, sarcoid or carcinomatous meningitis are possibilities. Finally, the patient may have a vascular lesion of the third nerve due to unrecognized diabetes. The appearance of the MRI abnormalities is non-specific. The lesions are potentially explainable by migraines, but are also consistent with hypertension or a vasculopathy. The patient denies a history of hypertension, is not currently hypertensive, and has no risk factors for vascular disease, but the possibility of a genetic disorder such as CADASIL cannot be excluded given the lack of paternal history. Plan: Problem 1. R IIIrd nerve palsy. The patient will undergo a cerebral angiogram to evaluate for an aneurysm, particularly a posterior communicating aneurysm. Patient has been informed of risks and benefits of this procedure and it is scheduled for AM. She will be kept NPO for the procedure. A lumbar puncture will be performed with opening pressure assessed and CSF sent for cell count and differential, protein, glucose, cultures and cytology. She will have her glucose and hemoglobin A1C drawn to evaluate for diabetes. She will have close observation for possible neurologic worsening including neuro checks every 4 hours for first 24 hours. She will be given an eye patch for comfort to eliminate the diplopia. Problem 2. Headache. She will be given a trial of naprosyn 400 mg po bid; if this is ineffective, she may require narcotic analgesia while her evaluation is being completed. If the cerebral angiogram and lumbar puncture are negative and her headache does not improve, she may be a candidate for IV dihydroergotamine treatment. Despite the infrequency of her migraines, the occurrence of a debilitating migraine with neurological deficits warrants the use of a prophylactic agent. A tricyclic antidepressant would be a good choice given her history of depression. Problem 3. Depression. The patient denies current symptoms and will continue Zoloft at current dose. Problem 4. Obesity. The patient requests referral to a dietician.