12468 TINAJONES ON NEUROLOGIC ASSESSMENT
LATEST UPDATED EXAM
SOAP Note Format
Patient Information:
T. J, a 28-year-old, African American Female with insurance
S.
CC (chief complaint): T N states that the reasons for seeking the care are that "I got into a little
fender bender a week ago and I have been getting these headaches ever since. Moreover, my
neck is sore too".
HPI: T.N came to the hospital complaining of a headache and neck stiffness acquired from a
minor fender bender. A week ago, she states that she was involved in an accident, which occurred
in a parking lot as a restrained passenger. She reports that the speed was 5-10 mph. She and the
driver refused to seek emergency care as they felt fine. However, two days later, she started
having bilateral temporal ache alongside neck ache. 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.
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, 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 he has been taking
alcohol occasionally.
Fam Hx: No history of migraine, seizures, Parkinson’s disease or Alzheimer’s disease
ROS:
CONSTITUTIONAL: No weight changes, generalized body weakness, fever, chills, fatigue,
sweats or night sweats.
HEENT: Head: no 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 tinnitus, hearing loss, vertigo, earache or discharge. Nose/Sinuses: No
rhinorrhea, stuffiness, 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.
This study source was downloaded by 100000865031992 from CourseHero.com on 04-16-2023 11:23:49 GMT -05:00
https://www.coursehero.com/file/44450165/12468-Tina-Jones-on-Neurologic-Assessmentdocx/
LATEST UPDATED EXAM
SOAP Note Format
Patient Information:
T. J, a 28-year-old, African American Female with insurance
S.
CC (chief complaint): T N states that the reasons for seeking the care are that "I got into a little
fender bender a week ago and I have been getting these headaches ever since. Moreover, my
neck is sore too".
HPI: T.N came to the hospital complaining of a headache and neck stiffness acquired from a
minor fender bender. A week ago, she states that she was involved in an accident, which occurred
in a parking lot as a restrained passenger. She reports that the speed was 5-10 mph. She and the
driver refused to seek emergency care as they felt fine. However, two days later, she started
having bilateral temporal ache alongside neck ache. 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.
This study source was downloaded by 100000865031992 from CourseHero.com on 04-16-2023 11:23:49 GMT -05:00
https://www.coursehero.com/file/44450165/12468-Tina-Jones-on-Neurologic-Assessmentdocx/
, 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 he has been taking
alcohol occasionally.
Fam Hx: No history of migraine, seizures, Parkinson’s disease or Alzheimer’s disease
ROS:
CONSTITUTIONAL: No weight changes, generalized body weakness, fever, chills, fatigue,
sweats or night sweats.
HEENT: Head: no 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 tinnitus, hearing loss, vertigo, earache or discharge. Nose/Sinuses: No
rhinorrhea, stuffiness, 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.
This study source was downloaded by 100000865031992 from CourseHero.com on 04-16-2023 11:23:49 GMT -05:00
https://www.coursehero.com/file/44450165/12468-Tina-Jones-on-Neurologic-Assessmentdocx/
