Neurological Soap note

Naser Feizi

MSN 572: Health Assessment

Dr Olson

United States University

August, 2022
 Neurology SOAP Examination

Video Link

SUBJECTIVE:

Patient ID: A.A, DOB: 3/1/1974, AGE. 44 y.o Middle-Eastern American female

CC:

"I keep having this terrible headaches that sometimes make me real sick and and start vomiting.”

HPI -HISTORY OF PRESENT ILLNESS:

The patient presented to the clinic today by herself with a report that she is getting terrible

headaches that according to her “makes me real sick”. A.A. states that the terrible headaches began

around six weeks ago and often cause her to be excessively sensitive to light that according to her

“any form of lightning hurts so I prefer to stay in dark”. the headache also causes nausea, visual

disturbances, speech disturbances and general body weakness of upto 3 days that she experiences 4

times each month. She also states that the headache gets more severe once she is about to have her

monthly menstrual flow. Any form of lightning either from the TV or her computer screen casue

her to feel weak, dizzy and throbbing headache on one side of the head which forces her to often lie

still on her bed with the room dark for a little relief. When aske d to rate the pain on a scale of 1 to

10, the patient replorts the pain can be a sterrible as 7/10 and worse on one side of the head while

the dizziness and nausea are more severe than the pain. The patient reports using ibuprofen 800mg,

to provide minimal relief for her symptoms. Patient denies any allergy to food, latex, environment

and latex.

PAST MEDICAL HISTORY: No recent hospitalizations and no known conditions

PAST MEDICAL PROCEDURES

None
MEDICATIONS

Ibuprofen 200mg Gel tablet

Allergies: No allergy reported.

FAMILY HISTORY

MGF: died of Cardiac Arrest at 76 years of age

MGM: died of stroke at 87 years of age

PGM: died of unknown causes at 89 years of age

PGF: died at 87 years of age with no health history

Father: alive, aged 79, with DM2, HTN,

Mother: alive, aged 74, with HTN, and migraine headaches,

Siblings: no health history

SOCIAL HISTORY

Sexual: Patient is married for 12 years to her husband whom she lives with in a heterosexual and

monogamous relationship. She reports having no concerns for STI, and have never been tested.

Smoking- no report of smoking, using Tobacco products or vaping and denies being around people

that smoke.

Substance use- reports that she does not exceed 1 glass of wine 2-3 days a week, and no form of

drug or marijuana products use. Also denies staying around people that use these substances.

Occupation- Nurse informatics officer in a local clinic.

Exercise/ Diet- Reports taking fruits, and vegetables daily. Denies taking any caffeinated beverage

or coffee but takes only diet coke occassionally. Preferred exercise includes hiking, swimming,

kayaking and jogging.

Sleep- patient has no difficulty falling asleep and sleeps 8-9 hours a night.
Stress-Patient reports having high levels of stress from her work,

IMMUNIZATIONS:

-Patient is up to date on all childhood vaccinations, Maderna vaccine 04/01/21, 4/29/21, Influenza

10/2020, and last Dtap booster 2016.

REVIEW OF SYSTEMS:

CONSTITUTIONAL: Reports episodes of fatigue, dizziness and vomiting caused by the headache.

EYES: denies pain, drainage or blurred vision, reported having her last eye exam in March 2020.

E/N/M/T: denies tinnitus, vertigo, hearing loss,or earache. No report of pain or lesions in the

mouth, tongue or throat. No report of difficulty breathing, rhinorrhea or nasal congestion. Denies

having any pain or difficulty swallowing, and no dysphagia.

CARDIOVASCULAR: denies palpitations, orthopnea angina, .

RESPIRATORY: Denies cough, wheezing, shortness of breath,and sputum production.

GASTROINTESTINAL: denies abdominal pain. constipation, diarrhea.

GENITOURINARY: denies urinary urgency, hesitancy, incontinence, pain, and frequency.

MUSCULOSKELETAL: Reports having pain on a scale of 5/10 in her right wrist that increases in

severity with usage of the wrist. Denies joint swelling, joint pain, muscle pain, stiffness, or

reduction in ROM.

INTEGUMENTARY/BREAST: Denies stria, lesions pruritus, rashes.

NEURO: denies paralysis, seizures, paresthesia's, or memory loss. Reports having headache that

started since two months ago and "makes me real sick" requiring some time off from work which

translates into inability to function for upto 3 days at one instance.

PSYCH: denies mood changes, anxiety, depression, or suicidal thoughts

fluctuations, and no report of polyphagia, polyuria, polydipsia, hair changes, libido, or problems

with sexual performance.

HEMATOLOGIC/LYMPHATIC: No report of easy bruising, petechia. excessive bleeding, .

ALLERGY/IMMUNOLOGY: No report of allergies and no incidence of immunocompromise from

medical history.

Objective:

VS: P: 67 SpO2 RA: 98% Pain: 0/10 BP:124/78 RR: 16 T: 97.8 f

Ht : 5’9 Wt : 160 BMI: 23.6

PHYSICAL EXAMINATION

General appearance: The patient is seated on the physical examination table, is resting

comfortably and appears calm. Patient is appropriate in response and makes consistent eye contact

with the examiner. The patient’s sitting and standing posture is intact and gait is smooth, and

symmetrical on approach. The patient’s appearance shows she is well-nourished and well-hydrated,

she shows no indications of having acute illness or distress. The patient’s breathing is normal, no

shallowness and is not labored. Patient has normal skin tone with no indications of jaundice,

erythema, pallor, and edema.

Mental status: Patient’s response to questions is appropriate and her comprehension is intact.

Cognition: LOC appropriate

Speech: Speech is clear and fluent

Orientation: Person, time, place, and event intact

Reasoning: Tested and intact

Memory: Remote and recent memory is tested and are found intact. Patient recalls objects 3/3 at 5

minutes.
Cranial Nerves:

CN I (olfactory): Patient’s sense of smell is intact, 2/2 nares bilaterally

CN II (Optic): The patient’s visual fields are observed on testing to be full on confrontation.

Fundoscopy was carried out and a healthy optic disc with distinct disc margins was observed. The

patient’s disc to cup ratio is 1:3. The retinal vasculature is examined and no abnormality was

detected. There were no cotton wool spots that might indicate a retinopathy observed, there were no

AV nicking, no tortuous vessels and no abnormality detected. Going further, the pupils are 4mm,

and shows PERRLA. The near triad of pupillary constriction on convergence, accommodation and

light reflex present bilaterally. The visual acuity is measured with a distance Snellen chart and

found to be 20/20 bilaterally.

CN III (ocular motor): The patient’s field of gaze is tested and no abnormality detected. The

oculomotor nerve innervates extraocular muscles such as the recti muscles and the inferior oblique

and all ocular movements are intact with no abnormality detected. The levator palpebrae superioris

that controls eye lid movement and innervated by CN III is also intact, same as the sphincter

pupillar that controls pupil constriction. Patient has no signs of nystagmus, there is no restriction in

eye ball movement and pupil reaction to light is intact.

CN IV (Trochlear): The fields of gaze of the patients eyes were tested for downward and medial

movement and no abnormality was detected. There are equally no indications of nystagmus.

CN V (Trigeminal): A sharp and soft stimuli was applied on the cheek, forehead and jaw

bilaterally to test for sensations from the three divisions of the trigeminal nerve and facial

sensations are intact, no abnormality detected.

CN VI (Abducens): The fields of gaze of the patients eyes were tested for lateral movement and

no abnormality was detected. There are equally no indications of nystagmus.

was tested for facial expressions like smile/frown/puffed cheeks/raised eyebrows and all were

intact.

CN VIII (Acoustic): The patient’s hearing was tested with a whisper and no abnormality was

detected. Weber test was conducted on both ears using a tuning fork and there are equal conduction

of sound in both ears and no abnormality detected Rinne test was conducted with bone to air

conduction recorded as 1:2 and bilateral hearing is intact.

CN IX (Glossal) and CN X (Vagus): the glossal and vsgus nerves were tested with open throat

when patient was asked to demonstrate "ahh." The uvula was observe to rise midline and patient

has no difficulty swallowing. No abnormalities with the cranial nerves and the gag reflex is present.

CN XI (Spinal Accessory): the spinal accessory nerve was tested as patient was asked to raise

shoulders (trapezius) and no abnormality detected. There is intact rotation of the head with

resistance (SCM) observed to be bilaterally equal 2+ strength.

CN XII (Hypoglossal): the hypoglossal nerve is tested with tongue protrusion and lateral

movement and no abnormality detected. Tongue is normal and midline. There is equal movement

of the tongue on both sides, it can press against the cheek. There is no abnormality such as drift or

deviation in movement of the tongue detected.

Sensory: The patient’s joint position sensory perception is intact, there are no abnormalities with

graphethesia and 2-point discrimination with eyes closed.sensory perceptions of touch, position,

pinprick, light and vibration all intact bilaterally in all extremities with no abnormality detected/

Reflexes: triceps +2, patellar +2, Biceps +2, and Achilles +2 bilaterally and no abnormality

detected. Babinski reflex observed, plantar reflex negative.

Motor strength: The patient’s bulk and muscle tone are good. Motor strength is 5/5 bilaterally in ,

shoulders, wrists, elbows, grip, feet, arms, forearms, ankles, and no abnormality detected.
ASSESSMENT:

Differential Diagnoses:

1. Tension headache – ICD 10 Code: G44-209

2. Migraine headache – ICD 10 Code: G43-909

3. Headaches, unspecified – ICD 10 Code: R51.9 (ICD10data, 2021).

Diagnosis:

Migraine headache.

The family health history of the patient shows strong presence of migraines. Because of the strong

genetic predispositions of migraine, the patient is at risk of the condition because her mother has it

(Lew & Punnapuzha, 2021). while the patient’s present symptoms such as the aura and dizziness

align with migraine, the possibility of the patient having tension headache is not eliminated which

imples additional tests such as neuroimaging is required to rule out the closely knitted differentials.

(Pescador Ruschel & De Jesus, 2021).

PLAN

Referral

Refer to neuroimaging (CT or MRI) to R/O brain bleed, tumor, stroke.

Treatment

Abortive management for migraine headache.

Sumatriptan (Imitrex) 25 mg. Can repeat in 2 hours if necessary but never to exceed 200 mg/day

(Skidmore-Roth, p. 1101, 2017).

Prophylaxis
Migraine headache prophylaxis. Topiramate (Topamax) 25 mg/daily. Can titrate by 25 mg/wk but

never to exceed 100 mg/daily in two divided doses.

Patient Education:

Patient should be educated on appropriate ways to take the medication to ensure adequate

bioavilability. The drugs are not be crushed, chewed or broken. Instead, the drugs are to be

swallowed with a full glass of water immediately the symptoms starts. Teach the patient to drink

small amounts of caffeine and take few minutes of rest in a dark room to manage migraine pain.

Patient should be educated on the common side effects of the medication such as depression and

the warning signs of suicide ideations (Skidmore-Roth, p. 1177, 2017).

Tension headache differentiation.

Patient should be informed that she may still experience tension headaches but she can tell the

difference as tension headache does not present with same visual disturbance as migraine.

The patient should be advised to take a break from the computer to avoid staying for long hours

which can trigger symptoms. A blue light filtering glasses should be prescribed for the patient to

cut harmful blue rays from the computer screen and the patient should also practice closing eyes

and looking at distance frequently to exercise the eye muscles and relieve tension headache.

Follow up:

Patient should appear to the clinic if symptoms do not resole after 3 days of medication. If

symptoms rersolve however, patient should present to the clinic in 2 weeks time for follow-up

evaluation with the results of the neuroimaging.

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., Soriano, R. P., & Bates, B. (2021). Bates' guide

to physical examination and history taking. Wolters Kluwer.

ICD10data. (2021). ICD-10—CM codes. ICD10data.

https://www.icd10data.com/ICD10CM/Codes/J00-J99/J30-J39/J30-/J30.2

Lew, C., & Punnapuzha, S. (2021, May 12). Migraine Medications. StatPearls [Internet].

https://www.ncbi.nlm.nih.gov/books/NBK553159/.

Pescador Ruschel, M. A., & De Jesus, O. (2021, February 7). Migraine Headache. StatPearls

[Internet]. https://www.ncbi.nlm.nih.gov/books/NBK560787/.

Skidmore-Roth, L. (2017). Mosby's 2017 Nursing drug reference. Elsevier Inc.