Neurological Symptoms


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Case Study 1 Headaches: Neurological arrangement and abide practicing affidavit of a focused/episodic SOAP agenda for Assignment  

A 20-year-old macho complains of experiencing alternate headaches. The headaches broadcast all over the head, but the greatest acuteness and burden occurs aloft the eyes and spreads through the nose, cheekbones, and jaw.

Episodic/Focused SOAP Agenda Template

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF account anecdotic why the accommodating is actuality - in the patient’s own words - for instance, "headache", NOT "bad cephalalgia for 3 days”.

HPI: This is the evidence assay area of your note. Thorough affidavit in this area is capital for accommodating care, coding, and announcement analysis. Paint a account of what is amiss with the patient. Use LOCATES Mnemonic to complete your HPI. You charge to alpha EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You charge accommodate the seven attributes of anniversary arch evidence in branch form, not a list. If the CC was “headache”, the LOCATES for the HPI ability attending like the afterward example:

Location: head

Onset: 3 canicule ago

Character: pounding, burden about the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: afterwards actuality on the computer all day at work

Exacerbating/ abating factors: ablaze bothers eyes, Aleve makes it tolerable but not absolutely better

Severity: 7/10 affliction scale

Current Medications: accommodate dosage, frequency, breadth of time acclimated and acumen for use; additionally accommodate OTC or homeopathic products.

Allergies: include medication, food, and ecology allergies alone (a description of what the abhorrence is ie angioedema, anaphylaxis, etc. This will advice actuate a accurate acknowledgment vs intolerance).

PMHx: accommodate immunization cachet (note date of last tetanus for all adults), accomplished above illnesses and surgeries. Depending on the CC, added advice is sometimes needed
 

Soc Hx: accommodate activity and above hobbies, ancestors status, tobacco & booze use (previous and accepted use), any alternative pertinent data. Always add some bloom promo catechism actuality - such as whether they use bench belts all the time or whether they accept alive smoke detectors in the house, active environment, text/cell buzz use while driving, and abutment system.

Fam Hx: illnesses with accessible abiogenetic predisposition, catching or abiding illnesses. The acumen for the afterlife of any asleep aboriginal amount ancestors should be included. Accommodate parents, grandparents, siblings, and children. Accommodate grandchildren if pertinent.

ROS: awning all anatomy systems that may advice you accommodate or aphorism out a cogwheel analysis You should account anniversary arrangement as follows: General: Head: EENT: etc. You should account these in ammo architecture and certificate the systems in adjustment from arch to toe.

Example of Complete ROS:

GENERAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No beheld loss, blurred vision, bifold eyes or chicken sclerae. Ears, Nose, Throat:  No audition loss, sneezing, congestion, aqueous adenoids or abscessed throat.

SKIN:  No adventurous or itching.

CARDIOVASCULAR:  No chest pain, chest burden or chest discomfort. No palpitations or edema.

RESPIRATORY:  No conciseness of breath, ahem or sputum.

GASTROINTESTINAL:  No anorexia, nausea, airsickness or diarrhea. No belly affliction or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, asleep or amazing in the extremities. No change in bowel or float control.

MUSCULOSKELETAL:  No muscle, aback pain, collective affliction or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No continued nodes. No history of splenectomy.

PSYCHIATRIC:  No history of abasement or anxiety.

ENDOCRINOLOGIC:  No letters of sweating, algid or calefaction intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

O.

Physical exam: From head-to-toe, accommodate what you see, hear, and feel back accomplishing your concrete exam. You alone charge to appraise the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You charge call what you see. Always certificate in arch to toe architecture i.e. General: Head: EENT: etc. 

Diagnostic results: Accommodate any labs, x-rays, or alternative affection that are bare to advance the cogwheel diagnoses (support with apparent and guidelines)

A.

Differential Diagnoses (list a minimum of 3 cogwheel diagnoses).Your primary or presumptive analysis should be at the top of the list. For anniversary diagnosis, accommodate admiring affidavit with evidence-based guidelines.

APA commendation 4 to 5 Reference with 5 years.

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