SOAP Notes : Central and Peripheral Nervous System Disorders

  • HPI: Mario is a 66-year-old Hispanic male who presents to the emergency room at his local hospital with acute aphasia, right facial droop, and right-sided weakness. The sudden onset of symptoms occurred at the post office, where he works part-time. One of his co-workers called 911. On the way to the hospital, the advanced squad team evaluated Mario’s neurologic deficits and glucose levels. The squad team then notified the receiving hospital of a possible stroke patient.Upon Mario’s arrival at the hospital, the ER nurse practitioner proceeded to gather the patient’s medical history from his wife, Lucinda, who accompanied him in the ambulance. She tells the nurse practitioner that Mario has a history of uncontrolled hypertension (and he was often non-compliant with his anti-hypertensive medications). His recent diagnosis of diabetes also was noted, as well as the oral hypoglycemic agents he was taking. The wife states both of Mario’s parents passed away from myocardial infarctions when they were in their late 60s.Smoking history: Mario is a smoker, usually smoking about a pack and a half each day.

    Exercise history: Mario leads a sedentary lifestyle that has contributed to his excess weight.

    At 5’5” inches, Mario weighs 255 pounds. BMI of: ____

  • What other family history, social history, and vital signs will you obtain from the wife and the patient?
  • What diagnostic tests will you order for Mario to determine what type of stroke he is having? List at least four diagnostic tests you would order and explain the rationale of each test.
  • The CT scan indicated a diagnosis of stroke. However, the lab tests and CT scan performed on Mario indicated there was no hemorrhage or early signs of ischemia. What education can you provide the family about the results of a CT scan for diagnosis of brain stroke?
  • You tell Mario’s wife that it is crucial to recognize the signs of an impending stroke. Describe at least four symptoms and signs of stroke you will educate the patient and family to look for.
  • You also discuss the RISK factors for stroke with Mario’s family. Lucinda realizes that Mario meets the criteria for all of them.
  • List at least four risk factors for having a stroke:
  • List at least three differential diagnoses for the symptoms listed above
  • What referrals will you make for Mario after his stroke? List at least three.

 

  • Kennedy-Malone, L., & Groenke-Duffy, E. (2023). Musculoskeletal disorders. In  Advanced practice nursing in the care of older adults (3rd ed.,  pp. 367-400). F.A. Davis.
  • Kennedy-Malone, L., & Groenke-Duffy, E. (2023). Central and peripheral nervous system disorders. In Advanced practice nursing in the care of older adults (3rd ed., pp. 401-436). F.A. Davis.
  • Kennedy-Malone, L., & Groenke-Duffy, E. (2023). Appendix B: Laboratory values in the older adult. In Advanced practice nursing in the care of older adults (3rd ed., pp. 581-582). F.A. Davis.

Note: See the labs that are relevant to this week’s topics.

To prepare:

  • Review the case study provided by your Instructor.
  • Reflect on the patient’s symptoms and aspects of disorders that may be present.
  • Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
  • Access the Focused SOAP Note Template in this week’s Resources.

The Assignment:

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

  • Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
  • Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessment results?
  • Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential is in or out. Explain the critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
  • Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
  • Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than five years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.

Answer

Focused SOAP Note

Patient Information:

Initials: M.M.

Age: 66

Sex: Male

Race: Hispanic

S (subjective)

CC (chief complaint): Lost the ability to speak, the right side has become weak, and the face is drooping.

HPI (history of present illness): A 66-year-old Hispanic man named Mario arrives at the emergency room after experiencing a sudden inability to speak, drooping on the right side of his face, and weakness on his right side. According to Lucinda, his wife, these symptoms appeared suddenly while he was working at the post office. Mario’s colleague quickly dialed 911 upon witnessing these neurological impairments. The advanced squad team who transported him to the hospital evaluated his neurological deficits and glucose levels during transit, leading them to suspect a stroke, which they relayed to the receiving hospital. Upon arriving at the hospital, Lucinda provided additional medical information about Mario. She highlighted his long-standing issues with high blood pressure that he has not been effectively managing due to non-compliance with prescribed antihypertensive medications. It was also disclosed that he recently received a diagnosis of diabetes and is currently taking oral hypoglycemic agents for treatment. Both of Mario’s parents passed away from myocardial infarctions when they were in their late 60s. Mario also has a history of smoking, with a habit of consuming approximately a pack and a half of cigarettes daily. Mario’s sedentary lifestyle has contributed to his excess weight; he stands 5’5″ tall and weighs 255 pounds, resulting in an elevated BMI.

Current Medications: Antihypertensive medication for his uncontrolled hypertension. Oral hypoglycemic agents for diabetes.

Allergies: No reported medication, food, or environmental allergies.

PMHx: Immunization is up to date according to state requirements for individuals his age.

Uncontrolled hypertension and recently diagnosed diabetes.


Soc and Substance Hx: Works at the post office. He has a history of smoking and currently consumes approximately one and a half packs of cigarettes daily. A sedentary lifestyle and smoking history are significant risk factors for the various health conditions present in the patient.

Fam Hx: Both parents passed away from myocardial infarction when they were in their late 60s.

Surgical Hx: No prior surgical procedures Reported.

Mental Hx: No concerns of anxiety, depression, history of self-harm practices, and suicidal or homicidal ideation.

Violence Hx: No Concerns about safety (personal, home, community, sexual (current and historical).

Reproductive Hx: deferred

ROS:

GENERAL: Reports no unintentional weight loss, chills, fever, weakness, or fatigue.

HEAD: Denies any head trauma or frequent or new headaches.

EENT (eyes, ears, nose, and throat):

Eyes: No vision loss, double vision, or yellowing of sclera. No history of cataracts or glaucoma.

Ears: No complaints of hearing loss or ringing in the ears.

Nose: No recent episodes of epistaxis, no congestion, or rhinorrhea.

Throat: No sore throat, hoarseness, or difficulty swallowing.

SKIN: Skin is intact, no rash, no itching, no recent changes in moles or skin lesions.

CARDIOVASCULAR: No new chest pain or discomfort. Denies palpitations. No known edema.

RESPIRATORY: No complaints of shortness of breath or cough. No history of asthma or COPD.

GASTROINTESTINAL: No anorexia, nausea, vomiting, diarrhea, or constipation. No abdominal pain.

GENITOURINARY: No burning on urination or increased frequency.

NEUROLOGICAL: No information on other neurological symptoms, such as headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities.

MUSCULOSKELETAL: no report of joint pain, especially in the mornings. No back pain, muscle pain, or recent injuries.

HEMATOLOGIC: No report of known bleeding disorders or easy bruising.

LYMPHATICS: No report of enlarged lymph nodes or any known history of lymphedema.

PSYCHIATRIC: No report of feelings of depression, anxiety, or other mood changes.

ENDOCRINOLOGIC: No report of excessive thirst (polydipsia) or excessive urination (polyuria). No known history of thyroid disease.

REPRODUCTIVE: Aged 66, no recent sexual activity reported. No known concerns with reproductive health.

ALLERGIES: No history of asthma, seasonal allergies, or other known drug allergies documented.

O (objective)

Physical exam

Vital signs: Weighs 255 pounds, 5 feet and a half, BMI 44

GENERAL: The patient appears in acute distress. He is oriented to person and place but is unable to speak. There is an evident right facial droop. Right-sided weakness is observed, with limited mobility in the right upper and lower extremities.

HEAD: No signs of trauma or injury.

EENT (Eyes, Ears, Nose, and Throat): The eyes appear symmetrical with equal pupil size and reactive to light. There is no nystagmus or ptosis noted. The tympanic membranes are intact. No nasal discharge or epistaxis was observed. The throat appears without erythema, exudate, or tonsillar enlargement.

CARDIOVASCULAR: Regular heart rate and rhythm. No murmurs, rubs, or gallops. Radial and pedal pulses are symmetric.

RESPIRATORY: No respiratory distress. Breath sounds are clear bilaterally.

GASTROINTESTINAL: Abdomen is soft and non-tender. No organomegaly, masses, or rebound tenderness was noted.

GENITOURINARY: Not assessed

NEUROLOGICAL: The patient exhibits expressive aphasia, right facial droop, and right-sided weakness in the upper and lower extremities. Strength is significantly reduced on the right side compared to the left. Reflexes are diminished on the right. The patient cannot follow complex commands.

MUSCULOSKELETAL: Not assessed

HEMATOLOGIC: Not assessed

LYMPHATICS: Not assessed

PSYCHIATRIC: The patient is non-cooperative for mental status examination due to neurological deficits.

ENDOCRINOLOGIC: Not assessed

Diagnostic Results:

The CT scan indicated a diagnosis of stroke, but the lab tests and CT scan performed on Mario indicated no hemorrhage or early signs of ischemia. Additional diagnostic tests may be required for a comprehensive evaluation and management.

CBC, CMP, Lipid panel, HgbA1C, TSH, CPK, PTT

A (assessment)

Differential diagnoses:

Ischemic Stroke

Treating a stroke promptly is essential because it is a medical emergency. Brain damage and other issues can be decreased with early intervention. An ischemic stroke happens when there is a reduction or interruption in the blood supply to a portion of the brain, depriving the brain tissue of oxygen and nutrients. Within minutes, brain cells start to die. When combined with risk factors like uncontrolled hypertension and a history of smoking, Mario’s abrupt onset of acute aphasia, right facial droop, and right-sided weakness strongly suggest an ischemic stroke. The guidelines for stroke assessment and management published by the American Stroke Association advise assessing and diagnosing stroke based on clinical symptoms, risk factors, and neuroimaging (e.g., CT or MRI scans) (American Heart Association, 2023).

Transient Ischemic Attack (TIA)

A transient ischemic attack, known as TIA, is a brief interruption of blood flow to the brain that typically resolves within 24 hours (American Stroke Association, 2023). Despite Mario’s persistent symptoms, it is essential to note that TIAs can sometimes mimic stroke symptoms. To accurately diagnose and differentiate between TIA and stroke, prompt assessment and diagnostic imaging are crucial according to the guidelines provided by the American Heart Association.

Intracerebral Hemorrhage

Intracerebral hemorrhage, a subtype of stroke, is a severe condition characterized by the formation of a hematoma within the brain tissue (Rajashekar & Liang, 2023). This can occur with or without blood extending into the ventricles. The risk factors for ICH include chronic hypertension, amyloid angiopathy, medication-induced anticoagulation, and vascular malformations. Symptoms of intracerebral hemorrhage often manifest suddenly as neurological deficits. Although an initial CT scan has ruled out hemorrhage in this case, it is crucial to consider this possibility, given the presentation. According to guidelines from the American Stroke Association for early management of patients with intracerebral hemorrhage, prompt imaging should be conducted to confirm or exclude hemorrhagic involvement.

P (plan)

Plan:

Ischemic Stroke

Neuroimaging: Order a CT angiogram (CTA) to assess the cerebral vasculature.

Consult with neurology for further evaluation and possible thrombolytic therapy.

Thrombolytic Therapy: If eligible and within the time frame, consider administering alteplase in accordance with American Stroke Association recommendations (Powers et al., 2019).

Constantly monitor vital signs and neurological status. Maintain an open airway.

Antiplatelet Therapy: Begin antiplatelet therapy (aspirin) at the same time as thrombolytic therapy.

Consult for Mechanical Thrombectomy: If a mechanical thrombectomy is indicated, consider endovascular treatment, as recommended by the 2018 guidelines (Qiu & Xu, 2020).

Reflection:

In this case, the patient’s medical state necessitated a multidisciplinary approach. The recommendations for managing acute ischemic stroke stress the significance of timely intervention and utilization of thrombolytic therapy when deemed appropriate. Furthermore, the expansion of the mechanical thrombectomy treatment time window highlighted the changing landscape of stroke management. Consideration of antiplatelet therapy, such as aspirin, for minor stroke patients, as well as specific patient group guidelines, all contribute to improved patient care.

Promotion of Health and Disease Prevention:

A solid health promotion and disease prevention plan is essential, taking into account the patient’s health risks, such as uncontrolled hypertension, smoking, and diabetes:

Medication Adherence: Educate the patient on the importance of taking prescribed medications, particularly blood pressure medication, to avoid recurrent strokes (Hui et al., 2022).

Ensure blood pressure control. Create an emphasis on the importance of blood pressure control in lowering the risk of stroke; this can be achieved through lifestyle changes, such as dietary changes and physical activity.

Smoking Cessation: Implement smoking cessation interventions and resources to assist the patient in quitting smoking, thereby lowering the risk of vascular damage.

Diabetes Management: ensuring the patient understands and adheres to their diabetes management.

Stroke Training: Educate the patient and family on how to recognize stroke symptoms and the importance of dialing 911 as soon as possible. Teach the “FAST” acronym (Face, Arms, Speech, Time) to recognize stroke symptoms.

Follow-up Appointments: Arrange for regular follow-up appointments to monitor risk factors and provide ongoing support.

 

References

American Heart Association. (2023). Stroke risk assessment. Www.stroke.org. https://www.stroke.org/en/about-stroke/stroke-risk-factors/stroke-risk-assessment

American Stroke Association. (2023). Transient ischemic attack (TIA). Www.stroke.org. https://www.stroke.org/en/about-stroke/types-of-stroke/tia-transient-ischemic-attack

Clinic, M. (2023, July 8). Stroke. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/stroke/symptoms-causes/syc-20350113

Hui, C., Tadi, P., & Patti, L. (2022). Ischemic Stroke. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499997/

Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., Brown, M., Demaerschalk, B. M., Hoh, B., Jauch, E. C., Kidwell, C. S., Leslie-Mazwi, T. M., Ovbiagele, B., Scott, P. A., Sheth, K. N., Southerland, A. M., Summers, D. V., Tirschwell, D. L., & on behalf of the American Heart Association Stroke Council. (2019). Guidelines for the early management of patients with Acute Ischemic Stroke: 2019 update to the 2018 guidelines for the early management of Acute Ischemic Stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke; a Journal of Cerebral Circulation50(12). https://doi.org/10.1161/str.000000000000021

Qiu, S., & Xu, Y. (2020). Guidelines for acute ischemic stroke treatment. Neuroscience Bulletin36(10), 1229–1232. https://doi.org/10.1007/s12264-020-00534-2

Rajashekar, D., & Liang, J. W. (2023). Intracerebral Hemorrhage. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK553103/

 

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