Assignment: SOAP Note for Tina Jones on Neurologic Assessment

Assignment: SOAP Note for Tina Jones on Neurologic Assessment

Assignment  SOAP Note for Tina Jones on Neurologic Assessment

Patient Information:

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

S.

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.

O.

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.

A.

Differential Diagnoses

1. 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.
2. 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).
3. 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:

1. Start the patient on ibuprofen 800mg PO three times a day with food for five days to manage the pain and fever.
2. Continue 500-1000 mg Tylenol OTC PO, after every 4 to 6 hours to manage the pain.
3. 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.

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Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.

Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?

Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.

Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.

If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.

I do not accept assignments that are two or more weeks late unless we have worked out an extension.

As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me:

Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.

Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

Important information for writing discussion questions and participation

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.

Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

• Your response needs to be a minimum of 150 words (not including your list of references)
• There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
• Include in-text citations in your response
• Do not include quotes—instead summarize and paraphrase the information
• Follow APA-7th edition
• Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

• A minimum of 6 responses per week, on at least 3 days of the week.
• Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
• Each response needs to be at least 75 words in length (does not include your list of references)
• Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
• Follow APA 7th edition
• Points will be deducted if the above is not followed
• Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
• Here are some helpful links
• Student paper example
• Citing Sources
• The Writing Center is a great resource