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MSN 572 Neuro Exam Soap Note.
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Running Head: NEURO SOAP NOTE 1MSN 572 Neuro Exam Soap Note
United States University
MSN 572
Advanced Health and Physical Assessment Across the
Lifespan
, Running Head: NEURO SOAP NOTE 2
Youtube Video Link: https://www.youtube.com/watch?v=NLHhbbpfa-0
ID: Patient OC , born 1/1/2000, 20 year old African Male Adult, a reliable historian, arrived alone to the clinic.
CC: “I have had a severe headache for the past two days.”
HPI : OC, a 20 year old African Male, is here for a sick visit. OP complains of headache on a scale of 6/10 to
the “all of my head”. OC states that the headache started two days ago and is has not gotten better. Pain is
generalized of the skull. OC states that the pain feels dull and aching, with slight pressure. OC states that the
pain does not radiate outside the head. OC states that the duration is “throughout the day”. OC has tried taking
pain medications for relief. OC states that the medication taken is ineffective, and has not tried another pain
medication for the headache. OC states that he took 80 mg of aspirin once per day for two days. OC states no
known aggravating factors. OC states that he does not experience fever, nausea, chest pain, dizziness, or
shortness of breath. OC tried using a cold towel placed on the back of his head day to help with the pain but it
has not worked. He also reports no changes in his regular diet. He states that he usually sleeps 7-8 hours a night,
but since two days ago he has unable to sleep well due to the pain. OC denies the headache getting worse upon
exertion. OC reports that recently he has been working overtime for extra money at work. Currently there are
no relieving factors. OC has no other complaints at this time. OC states he is in overall great physical health and
his last visit was 09/14/20 for a wellness exam. OC has had most normal health screenings as advised, and his
last cholesterol levels were done on 01/14/2020 and normal. OC is a sophomore at the Junior College
downtown, and lives alone.
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