6 cardinal fields of gaze cranial nerves

NUR 378: SOAP Note Example (Neuro)

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SUBJECTIVE DEMOGRAPHICS: Female nursing student, lives with parents. INITIALS: EB AGE: 23 DOB: 11/15/1989 INFORMANT/RELATIONSHIP: Patient INSURANCE: BCBS of MA CC: Well visit. HPI: Denies any complaints or problems. PAST HEALTH HISTORY / MEDICAL / SURGICAL / PSYCHIATRIC / OBSTETRIC: Denies MEDICATIONS: Denies ALLERGIES: No known; Denies food allergies such as peanut, fish, etc. allergy to any medications including over the counter and vitamins; any environmental allergy such as pollen, bee stings, etc. HABITS: Denies smoking tobacco; consumes alcoholic beverages usually wine once a week with friends; typically has 3 glasses over a 4-5 hours period; Denis any abuse of prescription drugs; cocaine, heroine, marijuana. ACCIDENTS, INJURIES, OCCUPATIONAL EXPOSURES: Denies any auto accidents, sports injuries, head injuries, open wounds or burns, occupational exposures CHILDHOOD ILLNESSES / IMMUNIZATIONS: 12yr old chicken pox; denies measles, mumps, rubella; All immunizations are current including measles, mumps, rubella, hepatitis, HPV and the most current influenza. TRAVEL / MILITARY SERVICE: Never traveled outside the country, only within the states; no military service FAMILY HISTORY: Student; Mother, 52 healthy; Father, 48 healthy; brother 20 healthy.

NUR 378: SOAP Note Example (Neuro)

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VIOLENCE AND ABUSE: Denies any physical, verbal, or emotional abuse at home or work. REVIEW OF SYSTEMS: General: denies night sweats, weight loss, fever, weak and exhaustion. Skin: Denies rashes, lumps, lesions, dryness, and change in size / color of moles, change in hair or nails. HEENT: H: Denies headache, dizziness, and lightheadedness. E: Denies change in vision, glasses, contact lenses, problem with double vision, blurred vision, redness, discharge, excessive tearing, dryness, and trauma E: Denies earaches, hearing aids, ringing in the ears, discharge/blood/pus N: Denies hearing loss, hearing aid, ear pain, earaches, ringing in the ear, discharge T: Denies sores, tooth or gum problems/pain, hoarseness, dentures Neck: Denies neck pain, neck masses, swallow glands, neck stiffness, goiter, Breasts: Denies lumps/masses, breast pain, and discharge from nipples. Respiratory: Denies cough, sob, wheezing, pain with breathing, hemoptysis, phlegm Cardiac: Denies heart problems, chest pain, high blood pressure, heart murmur, palpitations, dyspnea, edema GI: Denies nausea, vomiting, difficulty swallowing, pain on swallowing, loss of appetite, bloody or black stool, diarrhea, constipation. GU: Denies unusual urination, UTI, smell, urgency, burning, itching, kidney pain, nocutria, polyuria, incontinence PV: Denies swelling in the legs, feet, ankles, color change in fingers/toes. MS: Denies joint pain, stiffness, weakness, tenderness and back pains, arthritis, redness, swelling, and limitation of motion. Neuro: Denies headache, dizziness, fainting, blackouts, numbness, change in mood, speech or attention, judgment, vertigo, seizures, paralysis, tingling tremors, involuntary movements. Hematologic: Denies bruising easy, bleeding, anemia, past transfusions.

NUR 378: SOAP Note Example (Neuro)

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Endocrine: Denies intolerance hot and cold, excessive sweating, thirst/hunger, thyroid trouble, poluria, and change in shoe size. Psych: Denies decrease in energy level, fatigue, anxiety, depression, difficulty sleeping, guilt, concentration issues, loss of appetite, and thoughts of suicide, hallucinations.

FUNCTIONAL HEALTH PATTERNS:

Health Perception/Health Management Pattern

Perceives her health as “good”.

EB is typically a healthy, happy person. RS exercises 3 times per week doing 45-50 minutes of cardio. Eats breakfast, lunch and dinner; typically well balanced with fruits, vegetables, lean meats. Does not drink milk; she does not enjoy the taste. Denies any use of tobacco including cigarettes, cigars. Consumes alcoholic beverages usually wine once a week with friends; typically has 3 glasses over a 4-5 hours period. States she has a yearly check up each year with her primary care physician and obgyn.

Nutrition/ Metabolic Pattern

Eats breakfast, lunch and dinner; typically well balanced with fruits, vegetables, lean meats. Does not drink milk - does not enjoy the taste. Weight has been constant over the year, denies any problems chewing. Enjoys eating and exploring new foods.

Appetite is great with no change. Buys the foods she likes and is willing to try new foods. Energy level right now is “normal”.

Elimination Pattern

Urinates 5-6 times per day and usually has 2 bowel movements per day. Denies that there is any change in her bowel movements. Denies the use of laxatives and denies the use of assistance to get in and out of the bathroom.

Exercise and Activity Pattern

Exercises 3 times per week, she preforms 45 minutes of cardio during this time period. Has no problem performing activities of daily living such as bathing, brushing her hair, doing laundry, making meals, and cleaning the house. Usually wakes up, gets ready for the day, then either go

NUR 378: SOAP Note Example (Neuro)

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to class or work, comes home makes dinner, go for a run or to the gym and relaxes by watching TV or reading a book.

Cognitive and Perceptual Pattern

Currently is in no pain. No problems with her memory that is concerning. Speaks English and Spanish and currently a college student, studying nursing. Reports being good at decision- making and prioritizing.

Sleep/Rest Pattern

Receives 6-8 hours of sleep each night; she does feel refreshed when waking up. Sometimes takes daytimes naps and denies having difficulty falling asleep. Denies walking up in the middle of the night and she usually wakes up around the same time every day unless she might go to class earlier.

Roles and Relationship Pattern

Lives with her parents who are married and her younger brother. She is the older sister to her brother so she is a role model to him. Her family communicates well which is how they respond to stress. Reports family is fortunate enough that they have not had to deal with any serious family illness. RS stated that her mother takes care of her family members usually when someone is ill, but her father does step up and takes care of her mother when she is ill.

Works at a local ice shop, part time. She states it is a safe fun environment and enjoys working with her coworkers. Reports that work does not affect her health.

Coping and Stress Management Pattern

Reports that she handles stress well and good at multitasking and her mother helps her handle her stress when it may become overwhelming. States she feels comfortable enough to speak with everyone in her family when she has a problem but her oldest sister helps her the most.

NUR 378: SOAP Note Example (Neuro)

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Self-Perception/ Self- Concept

Describes her self has happy, intelligent and easy going. She looks forward to spending time with her family and friends. Reports she is comfortable with her body and identity. Reports she may get sad sometimes but she feels as though this is healthy way to cope with these things.

Sexuality/Reproductive Pattern

Reports being sexually active with her current boyfriend and uses condoms. Denies any change in her sexual pattern or any concerns in relation to her sexual functioning.

Values and Beliefs

Reports that her family, friends and colleges are extremely important to her along with her education. Reports being Christian, but is not involved in a religious group.

OBJECTIVE PHYSICAL EXAM: Mental Status: A/O to person, place, and time, calm and dressed appropriately/good hygiene. Memory (recent and remote) appears intact. Cranial Nerves: I: Identifies alcohol with each nostril. II: Using Snelling chart, vision 20/20 bilaterally. III, IV, VI: 6 cardinal fields of gaze intact. Pupils are equal, round, react to light, accommodate. No nystagmus or striabismus bilaterally. V: (Trigeminal) able to distinguish pain and light touch bilaterally, jaw strength strong, bilaterally. VII: Able to smile, frown, symmetric movements. VIII: Hearing intact to whispered voice at 2 ft, bilaterally. IX, X: soft palate/uvula rise symmetrically in midline. XI: Patient can turn head/shrug shoulders against resistance. XII: Tongue protrudes approximately in midline. Mild tremors appreciated. Motor: Muscle bulk/tone intake, strength rated 5+ bilaterally in upper and lower extremities, smooth gait, easy tandem walk, point-to-point and RSM intact in upper and lower extremities, Romberg and pronator drift both negative. Sensory: Intact to pain/light touch throughout, intact to vibration in distal digits, bilaterally.

NUR 378: SOAP Note Example (Neuro)

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Reflexes: Triceps, biceps, brachiordialis patella and Achilles all intact and rated 2+ bilaterally, no plantar response. ASSESSMENT: Healthy 23 year old female, no acute or chronic neurologic conditions. PLAN: PROVIDE YOUR PLAN…..