Neurological SOAP Note Example

Below is a nursing SOAP note for a neurological examination based on a case study, incorporating all applicable components and subcomponents, and utilizing the OLDCART acronym in the History of Present Illness (HPI) section:

Review: Other Nursing SOAP Notes Examples

• Psychiatric SOAP Note Example
• HEENT SOAP Note Example
• Respiratory SOAP Note Example
• Cardiovascular SOAP Note Example
• Abdominal SOAP Note Example
• Musculoskeletal SOAP Note Example
• Skin, Hair, and Nails SOAP Note Example
• Discharge SOAP Note Example

Subjective:

1. Chief Complaint: Patient reports severe headache and weakness in the right arm.
2. HPI (History of Present Illness):
   • Onset: The patient states that the symptoms started suddenly this morning.
   • Location: The patient reports experiencing the headache throughout their entire head, with no specific focal point. The weakness is isolated to the right arm.
   • Duration: The patient mentions that the symptoms have been constant since their onset.
   • Character: The patient describes the headache as a throbbing, intense pain. They report feeling weak in the right arm, with difficulty gripping objects.
   • Aggravating Factors: The patient reports that the headache worsens with movement and exposure to bright lights or loud noises.
   • Relieving Factors: The patient states that resting in a quiet, dark room provides temporary relief for the headache.
   • Treatment/Interventions Tried: The patient has taken over-the-counter pain relievers, but they have not provided significant relief.
3. Past Medical History: Document any relevant past medical conditions, surgical procedures, or previous neurological disorders that may be related to the current symptoms. Include details about any previous episodes of headaches or similar neurological events.
4. Allergy History: Inquire about any known allergies to medications, including pain relievers or specific neurological medications. Note the type of reaction experienced and any known allergens to avoid.
5. Medication History: Record the patient’s current and past medication history, including prescribed medications, over-the-counter pain relievers, or any other medications used for neurological conditions.
6. Social History: Explore the patient’s lifestyle habits, including sleep patterns, stress levels, and any recent changes in work or personal life that may contribute to the symptoms. Assess any history of substance use or exposure to toxins.
7. Review of Systems: Conduct a brief review of systems, focusing on symptoms related to the neurological system. Inquire about associated symptoms such as dizziness, visual disturbances, changes in coordination, or difficulty speaking.

Objective:

1. Vital Signs: Blood pressure: 130/80 mmHg, Heart rate: 72 bpm, Respiratory rate: 16 breaths per minute, Temperature: 36.8°C.
2. General Appearance: The patient appears in discomfort, rubbing their head and favoring the right arm. No signs of acute distress or neurological deficits.
3. Neurological Examination: Cranial nerves intact, normal muscle tone and strength in the left arm, reduced muscle strength in the right arm.

Assessment:

1. Medical Diagnosis: Migraine headache with associated right-sided weakness.
2. Problem Identification: Patient reports severe headache and weakness in the right arm.
3. Relevant Findings and Abnormalities: Throbbing headache, weakness isolated to the right arm.
4. Client Education Needs: Patient requires education on migraine management, triggers to avoid, self-care measures, and the importance of follow-up appointments.

Plan:

1. Medical Interventions:
   • Prescribe a specific migraine medication for pain relief and prevention.
   • Recommend lifestyle modifications, such as stress reduction techniques, regular sleep patterns, and dietary adjustments.
   • Discuss the use of cold packs or relaxation exercises for headache relief.
2. Patient Education:
   • Educate the patient about migraine triggers, such as certain foods, hormonal changes, or environmental factors, and the importance of avoiding them.
   • Instruct the patient on keeping a headache diary to identify triggers and patterns.
   • Provide information on the importance of managing stress and maintaining a healthy lifestyle.
3. Referrals or Consultations:
   • Refer the patient to a neurologist for further evaluation and consideration of advanced imaging or additional neurological testing.
   • Schedule a consultation with a physical therapist for evaluation and therapy for the right arm weakness.
4. Safety Measures:
   • Assess the patient’s home environment for any potential hazards or barriers to self-care during migraine attacks.
   • Educate the patient on when to seek immediate medical attention for sudden worsening of symptoms or signs of stroke.
5. Evaluation:
   • Schedule a follow-up appointment in one month to assess symptom improvement, evaluate medication effectiveness, and make any necessary adjustments to the management plan.
   • Monitor for any signs of worsening symptoms or complications related to the migraine or neurological condition.

• This example demonstrates a neurological SOAP note based on a case study, incorporating all applicable components and subcomponents.
• The subjective section captures the patient’s chief complaint and provides a detailed HPI using the OLDCART acronym.
• The objective section includes vital signs and examination findings related to the neurological system.
• The assessment section includes the medical diagnosis, relevant findings, and problem identification.
• The plan outlines the medical interventions, patient education, referrals or consultations, safety measures, and a plan for evaluation.