NR 509 Week 3 SOAP note - SOAP note Shadow Health Tina Jones Neurological Assessment

Initials: TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Rating: Allergies (and reaction) 170 cm 88 kg 139/ 87 82 bpm 16 98.9 99% Medication: Penicillin- rash/ hives Food: no known allergies Environment: Cat dander and dust- cat dander and dust- rhinorrhea, pruritic and periorbital edema, wheezing History of Present Illness (HPI) Chief Complaint (CC) “Headache & neck symptoms” CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom Onset Pain started 5 days ago after being involved in a MVC 2 days prior Location Headache pain localized to the crown & back of the head, and pain radiating down to bilateral, posterior cervical muscles Duration Report headaches last 1-2 hours and occur daily, neck pain has been constant for 5 days (2 days post MVC). Last headache was yesterday afternoon Characteristics Head pain is a dull ache, not sharp, cyclic, or rapid in crescendo. Pain does not radiate into back or arms. Head and neck pain severity rated 3 out of 10, and 4 out of 10 at its worst, reports slight pain and soreness to posterior cervical muscles. Headaches have no discernible trigger and are without visual disturbances or auras. Headaches occur at random times throughout the day. Patient was a restrained front-passenger in a MVC 7 days ago, denies any LOC or trauma to the head or neck. Vehicle was traveling at 15 mph when they were rear-ended, symptoms presented 2 days later. Aggravating Factors MVC seems to be primary cause 1 week ago, pain with head or neck ROM Relieving Factors Symptoms improve with rest, limiting ROM, and minor relief from Acetaminophen Treatment Rest, limiting ROM, and Acetaminophen Current Medications: Include dosage, frequency, length of time used an