Episodic/Focused SOAP Note – Neurological Symptoms

S.
CC: “Not being able to feel his toes in the left foot and numbness in the hell of the right foot and
a tingling sensation.”
HPI: The patient is a 48-year-old male who presents to the clinic with a history of diabetes
mellitus type 2 (T2D) and hypertension (HTN). He complaints of being unable to feel his toes in
the left foot. The symptoms started a month ago and have been persistent. The patient also
reports numbness in the right foot and heel and a tingling sensation. He denies hallucinations,
illusions, delusions, and suicidal ideation. He also denies shortness of breath, rashes, itching,
vomiting, diarrhea, depression, anxiety, muscle pain. The 48-year-old is living alone after
divorcing her 20-year-old wife five years ago.
Current Medications: Extended-release metformin 500mg qd; Norvasc 10 mg qd.
Allergies: Denies any allergies.
PMHx: The patient has a positive history of diabetes type 2 mellitus and HTN; both have been
adequately controlled.
Soc Hx: The patient is a software engineer with a leading tech company. He lives alone after
divorcing his wife five years ago. He has two all-grown sons who work and live in different
states, but visit occasionally during December holidays. He still enjoys a close relationship with
his wife and does not consider remarrying. He drinks at six bottles of beer and smokes a packet
weekly.
Fam Hx: Father died at 75 with stroke. He also had a long history with hypertension, chronic
kidney disease, and diabetes. Mother is currently battling breast cancer diabetes. Younger brother
is obese and is under long-term hypertension management. The uncle is battling neuropathy.
Symptoms include pain, tingling, and numbness in the extremities.
ROS:
GENERAL: Denies diarrhea, fever, chills, weight loss, muscle weakness, and fatigue.
HEENT: Eyes: Negative for blurred vision, visual loss, yellow sclerae, or double vision.
Ears, Nose, Throat:  Negative for hearing loss, congestion, sneezing, runny nose or sore
throat.
SKIN: Denies itching or rashes.
CARDIOVASCULAR: Negative for chest pain, pressure, or discomfort. Denies
palpitations or edema.

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RESPIRATORY: Negative for sputum, shortness of breath, or cough.
GASTROINTESTINAL: Negative for diarrhea, anorexia, vomiting, or nausea. Denies
abdominal pain.
GENITOURINARY: Negative for polyuria or polydipsia.
NEUROLOGICAL:  Negative for headache ataxia, paralysis, syncope, and dizziness.
Positive for numbness in the right foot’s heel and tingling. Denies changes in bladder and
bowel control.
MUSCULOSKELETAL:  Negatived for muscle, joint, and back pain. No muscle or joint
stiffness.
HEMATOLOGIC:  Negative for bruising, anemia, or bleeding.
LYMPHATICS:  No enlarged nodes or splenectomy.
PSYCHIATRIC:  Negative for anxiety or depression.
ENDOCRINOLOGIC:  Negative for cold/heat intolerance or sweating.
ALLERGIES:  No history of rhinitis, eczema, hives, or asthma.
O.
Vitals: BP 129/75; P 80; RR 17; TEMP 99; Wt 128; Ht 5,6; BMI 20.98
Physical exam:
HEENT: The head is normocephalic and atraumatic. Pupils are equal, round, reactive to
light, and accommodation (PERRLA). Sclera and conjunctiva are normal and clear.
Nares/nostrils are patent and open. The nasopharynx is clear with not obstructions. The
dentition is good.
Cardiovascular: The heart sounds (S1S2) are normal with no gallops, rubs, or murmurs.
Normoactive and benign bowel sounds are heard in all the four quadrants.
Skin: The skin is intact with no rashes, masses, lesions, or cyanosis.
Endocrinologic: Cranial nerves II-XII are intact without abnormalities in hearing, vision,
or facial movement. Muscle strength is “normal” without lower extremity weakness. The
patient can execute ankle inversion or dorsiflexion without any hiccups. However,
sensation in the left foot toes is reduced, especially in the distal areas. In all the left toes,
the patient is unable to feel the pinprick and light touch fully. The patient is also unable to

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feel temperature changes and light touch in the right heel. The patient also describes a
predominant tingling sensation in the right food that extents to the distal toes.
Diagnostic results:
 MRI scan of the Spine: Conducting an MRI scan of the spine (lumber) can provide an
image of the structural abnormalities of the spine bones that may be squeezing the spinal
nerves and yielding the observed symptoms, such as the tingling sensation and numbness
in the toes and heel. An MRI scan can show issues like spinal stenosis, herniated discs, or
other structural changes contributing to the patient’s symptoms (Zheng et al., 2021).
 NCS and EMG Tests: Electromyography (EMG) and nerve conduction studies (NCS) are
diagnostic tests that examine the electrical activity of nerves and muscles, often to the
lower or upper extremities. NCS and EMG test can assist in establishing muscle disease
nerve injury responsible for numbness and tingling sensation around the foot, toes, and
other areas of the legs or arms. It is often used to diagnose diseases such as a pinched
spinal nerve, carpal tunnel syndrome, myositis, ALS, or peripheral neuropathy (Merz,
2018).
 Complete blood count: Conducting a complete blood count (CBC) can assist in
identifying or ruling out anemia and blood infections as potential issues causing the
patient’s symptoms. Hansen’s disease (leprosy) is a bacterial infection that can affect
nerves, the skin, or respiratory tract, causing symptoms like numbness or tingling in the
extremities.
 CSF Analysis: Analyzing the patient’s cerebrospinal fluid can also help identify potential
signs of inflammation and infections.
 X-ray: Taking an X-ray of the left foot and the lumbar disc can assist in determining bone
fractures or structural changes that may be potentially contributing to the patient’s
symptoms, especially if the 48-year-old reports injuring himself or being involved in an
accident.
A.
Differential Diagnoses:
 Diabetic neuropathy: This is the number one candidate for this patient because of his
history with diabetes mellitus type 2. Diabetic neuropathy is one of the primary
complications associated with long-term diabetes, especially type 2. It can cause all the
symptoms exhibited by the patient, including loss of sensation, a tingling sensation, and
numbness in the distal lower extremities (Callaghan et al., 2020).
 Herniated disc: A herniated disc (also called ruptured, slipped, or bulged disc) is a
component of the lumber disc (nucleus) that is shoved out of the annulus, into the canal
of the spine due to a rupture or tear in the annulus (American Association of Neurological
Surgeons, n.d.). Herniated disc can squeeze or compress the spinal nerves serving the
lower extremities, causing the tingling, numbness, and loss of sensation – all symptoms
exhibited by the patient.
 Peripheral neuropathy due to accidents, infection, or injury: This can occur when
peripheral nerves (those found outside the spinal cord and brain) are damaged or injured

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due to accidents or infection. For the case of this patient, potential damage of nerves in
the left foot and toe may be causing the numbness, tingling sensation, and other
neurological symptoms.
 Peripheral artery disease: This condition occurs when blood flow to the extremities
(legs or arms) is reduced because of the narrowing of arteries. This is common in elderly
patients. The reduced blood flow can cause
P.  
This section is not required for the assignments in this course (NURS 6512) but will be required
for future courses.

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References

American Association of Neurological Surgeons. (n.d.). Herniated disc.
https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Herniated-Disc
Callaghan, B. C., Gallagher, G., Fridman, V., & Feldman, E. L. (2020). Diabetic neuropathy:
What does the future hold? Diabetologia, 63, 891–897. https://doi.org/10.1007/s00125-
020-05085-9
Merz, M. (2018). Electromyography (EMG) & nerve conduction studies (NCS). Mayfield Clinic.
https://mayfieldclinic.com/pe-emg.htm
Zheng, K., Wen, Z., & Li, D. (2021). The clinical diagnostic value of lumbar intervertebral disc
herniation based on MRI images. Journal of Healthcare Engineering, 2021. doi:
10.1155/2021/5594920