NR 509 Week 3 Neurology SOAP Note (version 1) 2019/2020, complete template solutions.

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S: Subjective Information the patient or patient representative told you This study source was downloaded by 100000860583932 from CourseHero.com on 01-27-2023 03:19:08 GMT -06:00 enter text. text... . to enter text. Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed. Diagnosed with Type 2 diabetes at the age of 24, non-compliant with diet and medications. Immunizations up to date with the exception of the flu shot. Diagnosed with asthma at the age of 2.5 and was last hospitalized at the age of 16. Heavy menstrual bleeding with irregular cycles, menarche at age 11. Denis surgical history, broken bones, or recent hospitalizations. Was hospitalized for asthma when she was a little girl and has never been intubated for asthma exacerbation. Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. Single, unmarried, no children Works 32 hours a week at Mid-American Copy & Ship as a supervisor Going to school to obtain a bachelors degree in accounting, two months away from graduating Enjoys reading books on her e-book reader, going to church activities and watching TV Denies tabacco use, friends smoke when they go out a couple times a month Used to use illicit drugs-marijuana, denies currently. Used marijuana “a lot” and “every weekend” for 5-6 years, from ages 15-21 and stopped because it “wasn’t fun” Last usage was age 20-21 Social alcohol use (2 times per month) Uses seatbelts consistently/Has working smoke detectors in her home Lives with her mom and sister Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Mother-HTN, HLD/Father-Type 2 diabetes, HLD, HTN-Died 1 year ago at age 58 in a car accident Brother-Obese, no other known health problems/Sister-Asthma-well controlled and is overall healthy Maternal grandmother-Died at age 73 from a stroke 5 y ago-Hx: HTN, HLD/ Maternal grandfather-Died at age 80 from heart attack-Hx: HTN, HLD Paternal grandmother-Possible HTN and HLD, PT unsure/ Paternal grandfather-Died from colon cancer, unknown medical hx, died years ago Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. This study source was downloaded by 100000860583932 from CourseHero.com on 01-27-2023 03:19:08 GMT -06:00 Constitutional Skin HEENT ☒Fatigue Denies ☒Weakness Denies ☒Fever/Chills Denies ☐Weight Gain Click or tap here to enter text. ☐Weight Loss Click or tap here to enter text. ☒Trouble Sleeping Denies ☒Night Sweats Denies ☐Other: Click or tap here to enter text. ☐Itching Click or tap here to enter text. ☐Rashes Click or tap here to enter text. ☐Nail Changes Click or tap here to enter text. ☐Skin Color Changes Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☒Diplopia Denies ☐Eye Pain Click or tap here to enter text. ☐Eye redness Click or tap here to enter text. ☒Vision changes Reports occasional blurry vision (pre-dating accident) ☒Photophobia Denies ☐Eye discharge Click or tap here to enter text. ☐Earache Click or tap here to enter text. ☒Tinnitus Denies ☐Epistaxis Click or tap here to enter text. ☒Vertigo Denies ☒Hearing Changes Denies ☐Hoarseness Click or tap here to enter text. ☐Oral Ulcers Click or tap here to enter text. ☐Sore Throat Click or tap here to enter text. ☐Congestion Click or tap here to enter text. ☐Rhinorrhea Click or tap here to enter text. ☒Other: Denies unilateral vision disturbance, denies difficulty swallowing Respiratory Neuro Cardiovascular ☐Cough Click or tap here to enter text. ☐Hemoptysis Click or tap here to enter text. ☐Dyspnea Click or tap here to enter text. ☐Wheezing Click or tap here to enter text. ☐Pain on Inspiration Click or tap here to enter text. ☐Sputum Production ☐Other: Click or tap here to enter text. ☒Syncope or Lightheadedness Denies ☒Headache Started 5 days ago after low speed car accident in parking lot, occurs daily for 1-2 hours at a time and located at crown and back of head, dull ache ☒Numbness Denies ☒Tingling Denies ☒Sensation Changes ☒Speech Deficits Denies. PT speaking clear and concise ☒Other: Denies hemiparesis, denies gait disturbance, denies loss of coordination, denies scotoma, denies facial flushing ☐Chest pain Click or tap here to enter text. ☐SOB Click or tap here to enter text. ☐Exercise Intolerance Click or tap here to enter text. ☐Orthopnea Click or tap here to enter text. ☐Edema Click or tap here to enter text. ☐Murmurs Click or tap here to enter text. ☐Palpitations Click or tap here to enter text. ☒Faintness Denies ☐OC Changes Click or tap here to enter text. ☐Claudications Click or tap here to enter text. ☐PND Click or tap here to enter text. ☐Other: Click or tap here to enter text. This study source was downloaded by 100000860583932 from CourseHero.com on 01-27-2023 03:19:08 GMT -06:00 MSK GI GU PSYCH ☒Pain Neck pain with movement of head and neck ☒Stiffness Neck stiffness ☐Crepitus Click or tap here to enter text. ☒Swelling Neck swelling, noticed it was hard to button the collar of her shirt ☐Limited ROM ☐Redness Click or tap here to enter text. ☐Misalignment Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☒Nausea/Vomiting Denies ☐Dysphasia Click or tap here to enter text. ☐Diarrhea Click or tap here to enter text. ☐Appetite Change Click or tap here to enter text. ☐Heartburn Click or tap here to enter text. ☐Blood in Stool Click or tap here to enter text. ☐Abdominal Pain Click or tap here to enter text. ☐Excessive Flatus Click or tap here to enter text. ☐Food Intolerance Click or tap here to enter text. ☐Rectal Bleeding Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Urgency Click or tap here to enter text. ☐Dysuria Click or tap here to enter text. ☐Burning Click or tap here to enter text. ☐Hematuria Click or tap here to enter text. ☐Polyuria Click or tap here to enter text. ☐Nocturia Click or tap here to enter text. ☐Incontinence Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☒Stress Reports increased stress due to school ☒Anxiety Denies ☒Depression Denies ☐Suicidal/Homicidal Ideation Click or tap here to enter text. ☒Memory Deficits Denies ☒Mood Changes Denies ☒Trouble Concentrating Denies ☒Other: Denies increased i [Show More]

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