Neurological SOAP Note

Identifying Information

Patient: G.C., 56 y/o, BF

DOB: 01/13/59

Visit: 04/20/15

Source & Reliability: Self-referred, seems reliable

Medical HX: No significant PMH. No childhood or adult diseases. Immunizations

UTD. She received the flu shot 11/01/2015.

Surgical HX: Brain aneurysm

OBGYN: G-0 T-0 P-0 A-0 L-0

Medications: No medications

Allergies: None

Personal/social HX: Married, works as an executive.

Drugs, Alcohol, or Smoking HX: No illegal drug use, or tobacco use, drinks 1 glass of

wine per week.

Family HX: Adopted and does not know her family history.



CC: “I have been having a hand tremor that has been increasingly frustrating for the past

2 years.”

HPI: 56-year-old black female presents with complaints of right-hand tremors (Location)

She reports that the tremors started 3 years ago (Onset), when putting her makeup on.

The right-hand tremor starts every morning when she wakes up (Timing), and will last

all day until bedtime (Duration). She reports no pain in her hands or other part of body

(Radiation). She reports no other symptoms with the right-hand tremor (Associating

Symptoms). She states that when she drinks alcohol the tremors seem improved

(Alleviating Factors). She states that nothing makes the right-hand tremors worse

(Aggravating Factors).


Review of Systems

General: Reports being “as healthy as can be” (-) fever (-) chills (-) recent weight gain or loss (-) weakness (-) fatigue. States her last physical exam was in 2014.

Skin, hair, & nails: (-) changes in skin (-) changes in hair (-) changes in nails.

HEENT: head – (-) injury (-) headaches (-) hair loss. eyes – (-) decreased vision (-) watery eyes (-) photosensitivity. last eye exam 1/2015. ears – (-) hearing problems (-) tinnitus (-) ear pain (-) drainage. nose – (-) nasal congestion (-) allergies (-) nasal drainage (-) epistasis

throat – (-) sore throat (-) tooth ache (-) pain or difficulty with swallowing. last dental exam 2 years ago.

Thorax/lungs: (-) chest pain (-) lung injury (-) lung disease (-) allergies (-) asthma.

Cardiovascular: (-) chest pain (-) irregular heartbeat (-) palpitations (-) murmurs (-) hypertension.
PVS: (-) extremity edema (-) coldness (-) leg cramps (-) ulcers.

Abdomen: Regular diet. (-) nausea (-) vomiting (-) bowel problems (-) abdominal pain (-) bloating (-) excess gas (-) diarrhea. Last bowel movement was yesterday.

GU: (-) urinary frequency (-) hesitancy (-) incontinence (-) nocturia (-) flank pain (-) burning (-) bleeding with urination.

Metabolic/Hematologic: (-) type I or II DM (-) thyroid problems (-) heat/cold intolerance (-) bruising (-) ease of bleeding. No history of blood transfusions.

Musculoskeletal: (-) trauma (-) injury.

Psychiatric: (-) trouble concentrating (-) nervousness (-) anxiety (-) panic attacks (-) mood changes (-) hearing voices (-) frequent unhappiness (-) desire to harm self/others (-) sleep trouble (-) nightmares (-) memory loss (-) excessive life stresses. No recent deaths in family or close friends.

Neurologic: (-) history of stroke (-) seizures (-) frequent/incapacitating headache (+) tremors in right hand (-) numbness in feet.



Vital Signs: B/P 120/70, P-80, R-20, T-98.4, BMI 38, Wt 120Lbs, HT 5’5.

General: Friendly, well-groomed, AAOX3, good eye contact and speech, appears relaxed and calm. Reliable historian.

Physical Assessment

Hair: Average texture dark brown, shiny hair. Evenly distributed on scalp with no breakage,

alopecia, dryness or infestations.

Skin: Warm, dry, supple, no bruises, rashes, or suspicious nevi to exposed skin.

Nails: Smooth and well manicured without clubbing or cyanosis. Capillary refill to finger pad is < 2 sec.

Head/Neck: Normocephalic/atraumatic, no bumps, bruises, lesions. Scalp pink and dry. No sinus tenderness, and no palpable lymph node enlargement or tenderness. Neck supple; thyroid isthmus palpable, lobes not felt. Trachea midline.

Eyes: Pupils 4mm constricting to 2mm, PERRLA, vision 20/20 in each eye, vision fields full by confrontation. negative strabismus and nystagmus, disk margins sharp, without hemorrhages, exudates. No anterior narrowing. Conjunctiva pink; sclera white.

Ears: Acuity good to whispered voice. TM pearly white and intact with no redness or bulging. Cone of light visible bilaterally (5 o’clock right, 7 o’clock left).

Nose: Turbinates intact, nares patent, septum midline, No tenderness over maxillary sinuses. mucosa pink with no swelling. No nasal flaring or discharge.

Throat/mouth: Membranes pink and moist. Uvula is midline, tonsils at pillars, no redness or exudates.

Lungs: Respirations 12 breaths/min, breath sounds vesicular, no rhonchi, wheezes, or crackles present. Lungs resonant. Thorax is symmetric, and the diaphragms descend 4 cm bilaterally.

Heart: No Scratching noise heard at lower left sternal border. Apical pulse 90 bpm on auscultation. S1 and S2 regular rate and rhythm with no splitting, S1 best at apex, S2 best at base, with no S3 or S4. Carotid upstrokes brisk with no bruits. No JVD. PMI palpable at 5th ICS 7cm lateral to the midsternal line, discrete and tapping. No heaves, lifts, or thrills. No rubs, gallops, murmurs, or opening snaps. Pain not elicited with chest wall palpation.

Breasts: Deferred per patient’s request.

Abdomen: Protuberant. Normoactive BS x 4 quadrants. No abdominal pulsations or bruits. No palpable masses or hepatosplenomegaly. Kidneys not felt, no flank pain or CVA tenderness.

Lymph Nodes: Head, neck, axilla, epitrochlear, and inguinal lymph nodes nonpalpable.

Extremities: Extremities are warm without edema. No varicosities or stasis. Calves are supple and non-tender. No femoral bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulse are all 2+ and symmetric. Full range of motion to all extremities.

Genitals: Deferred at patient’s request

Rectum/Anus: Deferred at patient’s request

Neurologic: AAOX3, cooperative and calm. Cranial nerves II-XII intact. Right hand tremors noted. Normal gait. Maintains balance with eyes closed. Good, even strength and muscle tone. Reflexes are 2+ and symmetric.


Diagnosis- Essential Tremors

Differential diagnosis:

  1. Parkinsons Disease
  2. Distal Symmetric sensorimotor polyneuropathy
  3. Autonomic Dysfunction
  4. Mononeuritis Multiplex
  5. Diabetic Neuropathy
  6. Diabetic Amyotrophy



Essential Tremor:

Rational for Essential Tremor is unsteadiness of right hand with rhythmic shaking. Essential tremors are uncontrolled, rhythmic shaking that often occurs in the hands (McCance, Huether, & Brashers, 2010). Some medications that can make tremors worse are: corticosteroids, valproic acid, antidepressants, antipsychotics, and adrenergic agonists. Tremors caused by medications is not a concern because GC is not on medications. However, the impairment of essential tremors on GC’s life may warrant medication. Medications used for the treatment of the essential tremor are: Primidone, Propranolol, clonazepam, and botulinum toxin injections. The patient should be informed about all of the treatment options available and should be encouraged to use the non-medical options before medication (Dunphy et al., 2011).

Obtain CBC, BMP, B12, TSH, Sed Rate, HbA1C.

Plan of care would be to check blood levels for B12, metabolic panel, complete blood count, blood glucose level, HbA1C, thyroid function, and erythrocyte sedimentation rate. A low B12, H&H, blood glucose, elevated sed rate, high or low electrolytes can cause neuropathy symptoms (Bickley, 2013).

Order CT/MRI of head

To diagnose essential hand tremor, the NP must observe the tremors and rule out any other potential causes. A CT/MRI of the head is ordered to rule out any underlying conditions or brain abnormalities, such as brain tumor (Bickley, 2013).

Discuss treatment options with the patient

Non-medical therapy includes: applying wrist weights that can help dampen the

tremors. The treatment of essential tremors may warrant medication. Medications

used for the treatment of the essential tremor are: Primidone, Propranolol,

clonazepam, and botulinum toxin injections. The patient should be informed about all

of the treatment options available and should be encouraged to use the non-medical

options before medication (Dunphy et al., 2011).

Discuss diet with the patient

Avoiding dietary stimulants such as caffeine because caffeine may make tremors worse (Bickley, 2013). It is important to educate the patient on diabetic prevention by eating healthy and doing exercise (the patient is already doing these things) and to report any changes, worsening in the numbness (Bates & Szilagyi, 2013).


A follow-up call will be made to the patient with his results and patient will be notified of any changes in the treatment plan and lab results. A follow-up visit will be scheduled to reassess the treatment plan and make changes if needed (Bickley, 2013).


Bickley, L. S., & Szilagyi, P. G. (2013). Bates’ guide to physical examination and history taking (11th ed.).

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary Care: The Art and Science of Advanced Practice Nursing (3rd ed.). Philadelphia, PA: F.A. Davis.

McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2010). Pathophysiology: The

biologic basis for disease in adults and children (6th ed.).