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

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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 50’s 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

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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/ex

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