Paper instructions:

 

REFER TO THE UPLOADED FILES I INCLUDED PLUS USE TWO SCHOLARLY PEER-REVIEWED ARTICLES WRITTEN IN THE LAST  3 YEARS!

 

Create a focused SOAP note write-up for the assessment of the *NEUROLOGIC SYSTEM* for a Migraine Headache. The uploaded document titled “*Model soap skin and abdomen“ will serve only as a template for how a SOAP note is write involving a focussed health history and physical exam of the patient’s neurological system.  The final product should mirror this paper’s layout and addresses each body system in the subjective section of the layout of the paper, while the objective section (use JARVIS) focuses on assessing the neurological system, MENTIONING EACH STATEMENT BELOW. 

 

THEN providing an assessment plus a Migraine Headache diagnosis (including two other unlikely differential diagnoses 1Cluster Headacheand 2 Tension-type headaches. ) then finishing with a plan that includes why a follow-up exam is also needed (Use LEWIS & DAINES files).

 

ALL CRANIAL NERVES MUST BE  MENTIONED IN THE PAPER’S OBJECTIVE FINDINgs

 

Again All of this is theoretical and should have NORMAL FINDINGS (See JARVIS File).

 

CN I (smell),  CN II (visual acuity, visual fields), BILATERALLY CN III, IV, VI (extraocular movements),  CN V (facial sensation and jaw movements),  CN VII (facial movements),   CN VIlI (hearing),  CN IX/X (swallowing and rise of the palate, gag reflex),  CN XI (shoulder movements), and head turns CN XII (tongue symmetry, position, and movement)

Additionally NORMAL FINDINGS. For the following tests musts be included (See JARVIS File)

 

       Assess coordination of upper extremities     (rapid finger tapping and alternating movements      or finger to nose test)

 

     Assess coordination of lower extremities    (foot tapping or heel to shin test)

        Assess gait including   ⁃ walking heel to toe,   ⁃ walking on toes,   ⁃ hopping in place,    âƒ rising from a chair without Support

 

        Romberg Test     (ask the patient to stand with feet together and eyes open      and then close eyes for 30 to 60 seconds without support)

 

           Pronator Drift    (ask the patient to stand for 0 to 30 seconds with eyes closed       and both arms held straight forward with palms up)

 

Motor System/Muscle Strength Testing

      Inspect muscles at rest and during movement     noting tremors, tics, fasciculations, size and contour, symmetry, and atrophy

     Assess elbows: flexion and extension     (elbows are flexed,    thumbs toward the patient;     apply resistance at wrists while patient flexes then extends elbows)

 

       Assess wrists: extension (patient makes a fist,     arms out in front;       try to push down on hands while the patient resists)

       Assess grip strength      (ask the patient to grasp your second and third fingers)

 

       Assess finger abduction     (patients spreads fingers apart wide;      try to force them together by pressing on lateral aspect of index and fourth fingers)

 

      Assess hips: flexion and extension    (With patient seated, place hand on thigh,    ask patient to raise leg against resistance.     Then, place hand under thigh and ask patient to push down.      Bilateral -can do flexion and extension on opposite sides simultaneously

 

        Assess hips: abduction and adduction    (With patient seated, legs relaxed, place your hands on lateral aspect of both knees and offer     resistance to further abduction [Don’t let me push your legs apart               Now move hands to medial aspect of knees and ask           against resistance [Don’t let me push your legs together])

 

     Assess knees: flexion and extension    (seated, place hands on shins and ask to straighten knee against resistance;     then curl fingers around to grasp lower leg and     ask patient to flex against resistance)

 

     Ankles: dorsiflexion and plantar flexion (place hands beneath both feet;    ask patient to press down like stepping on a gas pedal,     then move fingers to dorsal aspect of foot and      ask patient to pull up against resistance)

 

Sensory System

 

      Test for light touch, pain,     temperature,   proprioception (position),               vibration, light touch,       discriminative sensation          (stereognosis,           graphesthesia,                   discrimination,         point localization,                extinction)

 

Reflexes

 

        points: Assess biceps reflex     (patient’s arm is flexed, palms down;       with your thumb over biceps tendon, strike thumb)

     Assess triceps reflex      (patient’s arm is down; strike tendon above elbow)

    Assess brachioradialis reflex patient’s forearm partly pronated;      strike radius point above wrist)

 

      Assess knee jerk reflex      (patient’s knee flexed; tap patellar tendon just below patella)

 

       Assess ankle jerk reflex (holding patient’s foot in slight dorsiflexion,     strike Achilles tendon)

 

Special Techniques patient supine

 

       Assess for meningeal signs    Brudzinski sign – Flex neck and watch for flexion of hips and knees;     Kernig sign – Flex leg at hip and knee, straighten leg, and look for pain and increased     resistance)   

 

All findings should include CITATIONS!

 

Paper’s content: create a fictional case study of a 34-year-old female patient (S.S.) with a Cheif Complaint of MIGRAINE HEADACHES using the reading from the uploaded document The patient is coming in for a wellness exam but still suffers from migraine headaches, already diagnosed by a past healthcare provider, and is receiving medication for this ailment but continues to have headaches, MORE COMMONLY IN THE EVENINGS. She currently takes 325 mg acetametaphine as needed by mouth. The health history should contain expected findings for a generic patient with headaches all of the other findings are normal.   

 

– The SOAP Note paper is based upon a theoretical health history physical examination and needs to contain all of the items listed above with *normal findings cited from  JARVIS   – The documentation of the patient’s history and recorded findings should come from JARVIS. The assessment, planning, and follow-up come from the two “*LEWIS & DAINES” uploaded documents, along with 2 other *peer-reviewed scholarly sources dating published in the last three years.

 

The planning and follow up should be based on the information from LEWISThe three required differential diagnoses will be 1) Angina, Chronic Stable from Coronary artery disease 2) Angina, Unstable from Acute Coronary Syndrome 3) Gastroesophageal Reflux Disease. Citation for the assessment and planning section.    The patient\’s background information and assessment data can be fabricated to complete the narrative of the SOAP but the paper MUST contain all of the required sections of a SAOP Note and are listed below with the grading rubric in bracets. All findings MUST be cited.  

 

Here is the paper’s rubric.

 

Subjective – 25%                                                 Information about the patient (3 points)                             Name (initials only); age, and gender                             Source of information; note relationship to patient, if relevant                             Reliability of information                         Chief Complaint (1 point)       

                                          History of Presenting Illness (8 points)                                                     Location                             Quality                             Quantity or severity                             Timing (onset, duration, frequency)                             Setting in which it occurs                             Factors that aggravate or relieve the symptoms                             Associated manifestations            

             Review of Focus System(s) (5 points)   

 

                                              Medications/Allergies (3 points)                                                 History (5 points)                                                     

Past Medical History                             Past Surgical HistoryFamily History                             Social History                             Health Maintenance Practices   [Patient described in appropriate detail Concise and clear chief complaint as described by the patient   HPI includes all components with appropriate detail   Comprehensive review of focus system(s) includes pertinent negatives   Name, dose, route, and frequency of prescribed and over-the-counter medications noted, including compliance;   Allergies to medications and reactions noted   Comprehensive health history is appropriate to the reason for the visit and includes pertinent negatives – 20 points]   

 

Objective – 30%   Physical exam includes appropriate areas for Chief Complaint, History of Presenting Illness, and Review of Systems (20 points)   Appropriate techniques of examination used to identify pertinent findings (10 points)   [Appropriate areas and systems included in physical assessment   Comprehensive techniques of observation, palpation, percussion, and auscultation noted including special assessments as appropriate – 30 points]   

 

Assessment – 20%   Differential diagnoses are supported by subjective and objective findings (15 points)   Scholarly resources support differential diagnoses (5 points)   [Three differential diagnoses are supported by findings and include worst-case scenario   Rationale for differential diagnoses provided by scholarly resources – 20 points]   

 

Plan – 15% Comprehensive plan to address likely differential diagnosis includes (9 points)       â€¢    Diagnostic testing     â€¢    Pharmacologic intervention     â€¢    Non-pharmacologic intervention     â€¢    Referrals     â€¢    Patient education     â€¢    Follow-up   Plan is supported by appropriate and current practice guidelines (6 points)   [Comprehensive plan includes all components Appropriate and current guidelines cited – 15 points]   

 

Documentation – 10% Documentation follows SOAP template, is logical, and in correct format (10 points)   [Logical and systematic organization of data Correct terminology, spelling, and grammar Scholarly resources noted in correct APA format – 10 points]

 

 Include the following reference0 plus ntw3o articles:   

 

Dains, J.E., Baumann, L.C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). Boston: Elsevier. ISBN-13: 978-0323266253 

 

Jarvis, C. (2015). Physical examination and health assessment (7th ed.). W B Saunders

 

Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. (2017). 

Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). St. Louis: Elsevier