In this case study it follows an 89-year-old man named Mr. Chestnut, who was admitted into the hospital for complaints of pain in his head. The associated system with this case study is the neurological system, which is the system in the human body that deals with a network of nerves and cells that send messages from the brain and spinal cord to the rest of the body (Mandal, 2013). Based on this case study a SOAP note, which consists of a subjective data, objective data, an assessment, and a plan, will be created to help identify and assess the condition of the patient.

Subjective:
The patient, Mr. Chestnut, is an 89-year-old male, who was admitted into the care facility with his caregiver/family member, complaining of pain in his head. The patient states that the pain began two days ago, and has been fluctuating …show more content…
Chestnut, an 89-year-old male. His main reason for visiting was he complained of pain in his head that he has been experiencing for the past few days. States that the pain has been in fluctuations and described as a moderate, throbbing/pulsating pain occurring on both sides of the head, more specifically the temporal region. The pain is worse with movement and radiates to the neck causing soreness and experiencing blurred vision and sensitivity to light. The patient’s vital signs indicate that the patient’s vitals are slightly above average and that he is experiencing high blood pressure. His neurological exam shows that the patient has difficulty with his field and peripheral of vision and was sensitive to the light. stated that there was pain in his neck when performing movements of the head and shoulders. The patient also shows other signs mostly related to his age and not necessarily the main problem. Diagnosis; The patient maybe experiencing Migraine headaches or Tension-type headaches from what is gathered from the assessments. the migraine headaches maybe caused from the current medication he is taking and his sleeping