NURS 612 Neurological Tina Jones SOAP >Assessment (diagnosis [primary and differential diagnosis]) Plan (treatment, education, and follow up plan)
What brought you here today (eg. headache) “I got into a little fender bender a week ago and I've been getting these headaches ever since.” Histo r y of P r ese nt Illn ess Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form Onset Patient is a 28-year-old African American woman who presented to the clinic complaining of a headache and neck stiffness that started 2 days after she was in a minor fender bender. She states that she was a restrained passenger in an accident in a parking lot one week ago. She believes the speed to be approximately 5-10 mph. She did not seek emergent care and felt no symptoms after the accident. She was not under the influence at the time of the accident. Two days later she developed a dull ache in bilateral temporal regions accompanied by neck ache. She states that she feels as though her neck may be slightly s
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