Donald Davis

10/26/17

SOAP Note

S. Ted Connor, a 40 year old white male, presents to the clinic today reporting, “I am having trouble
walking.” Pt reports that he had a fall two weeks ago and sprained his ankle. Pt went to Urgent care and
was placed in a walking boot with no fractures. Pt then followed up his general practioneer two days
later. GP reports only the sprained ankle. Pt was concerned with no decrease in symptoms in foot. Pt
reports that he is having trouble lifting his toes while walking. Pt also reports that he is having
paresthesia in his R. thigh that comes and goes, also paresthesia in his L. hand and fingers. Pt reports
that at times he is losing the sight to the right in his peripheral vision. Pt also reports that he has had
fatigue and dizziness for the last two months that is worse in the morning and that gets better in the
afternoon.

Review of Systems

Constitution: Pt does not have any symptoms dealing with his constitution.

EENT: Pt is having some intermittent loss of vision in R. periphery.

Cardiovascular: Pt has no cardiovascular symptoms.

Respiratory: Pt has no respiratory symptoms

GI/GU: Pt is not having any GI/GU problems

MSK: Pt is having foot drop in R. LE. Pt had a fall two weeks ago with sprained R. ankle

Neuro: Pt is having foot drop on R. LE, paresthesia in R. thigh, and L. hand.

Endocrine: Pt does not have any endocrine symptoms.

Past Medical History

Pt has no relevant past medical history.

Family History

Pts father has had Parkinson’s disease for the last 10 years and is currently 65

Pt’s grandfather died of ALS.

Social History

Pt is a homemaker. Pt has a 2 pack year history and a occasional social drinker on the weekend with 2-3
drinks. Pt reports that he has a strict healthy diet and consumes only water.

O. Vitals BP 122/80
DTR- 1+ in UE and LE except for R. LE was 3+ hypereflexive.

Myotome- UE 5/5 LE: R. Knee extension quads 3+/5 L. Knee extension 5/5 , R. hip flexion 3+/5 L. 5/5, DF
R. 3+/5 L. 5/5, Ankle inversion R. 3+/5 L. 5/5, Ankle Evr. R. 3+/5 L. 5/5, Great toe R. 3+/5 L. 5/5

Dermatome: UE Normal LE: L. LE normal, R. LE decreased from L3 down, L. LE normal.

Gait. Pt had R. foot drop with increased hip flexion to compensate.

Rhomberg: Pt unable to maintain balance >5 seconds with eyes closed.

Pathological reflex: Babinski (+ for toe extension and flair)

A. 1. Multiple Sclerosis

2. ALS

3. TIA

P. Refer to general practioneer with findings from exam. Cotreat with GP or Neurologist.