Group 1: CASE STUDY: A 20-year-old male complains of experiencing intermittent headaches.
CASE STUDY: A 20-year-old male complains of experiencing intermittent headaches.
A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.
Week 9 Assignment NURS 6512
You will be focus on Neurological Symptoms. Group 1 has Case study 1 and Group 2 Numbness and Pain. You have 2 required assignments for this Week.
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Assignment 1: Case Study Assignment: Assessing Neurological Symptoms
To Prepare for CASE STUDY: A 20-year-old male complains of experiencing intermittent headaches.
By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
With regard to the case study you were assigned:
Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study you were assigned.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least three possible conditions that may be considered in a differential diagnosis for the patient.
The Case Study Assignment
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
By Day 6 of Week 9
Submit your Assignment.
Submission and Grading Information
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Sample Approach
A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw
Think about what kind of background information you would need to get from the patient in the case study that you have been assigned.
When taking the patient’s medical history, it would have been helpful to inquire further about the headache. The examiner ought to have relied more heavily on SOCRATES in order to evaluate the headache. According to Gregory (2019), the SOCRATES mnemonic is a pain assessment tool that is widely used by healthcare providers to Help them in remembering key questions about the patient’s pain. [Citation needed] The beginning, the nature, the associated symptoms, the severity, or the factors that are either aggravating or relieving. In addition, the patient should have been questioned regarding the presence of any previous head injuries, visual disturbances, dizziness, nausea, vomiting, photophobia, fever, sleep disturbances, neurological deficits, neck stiffness, tenderness in the temporal region, rash, or loss of weight.
Think about what kinds of diagnostic tests and physical examinations would be most appropriate for the patient so that you can find out more about their condition. How would the findings be incorporated into the diagnostic process?
According to Lee et al. (2018), patients who suffer from headaches should undergo a physical examination as soon as possible to help eliminate the possibility of secondary headaches. A patient who comes in complaining of headaches will have their vital signs monitored, their general appearance evaluated, a general examination performed, and a comprehensive neurological examination performed as part of their physical examination. The patient’s scalp is palpated for any swellings or tenderness, the ipsilateral temporal artery is palpated, and the temporomandibular joints are palpated for any tenderness or crepitance as the patient opens and closes their mouth. All of these examinations are performed simultaneously. Examining the area around the eye for any signs of conjunctival injection, such as flushing, lacrimation, or bleeding. In addition to evaluating the visual fields, the pupils’ sizes, responses to light, extraocular movements, and other characteristics are examined. It is important to conduct a fundus examination to look for papilledema and spontaneous retinal venous pulsations. The oropharynx should be examined for any signs of swelling, and the patient’s teeth should be palpated to detect any sensitivity. Flexion of the neck is performed to check for any signs of stiffness or discomfort, and palpation of the cervical spine is done to check for any signs of tenderness.
The diagnostic imaging workup for headaches is very important in determining whether or not the patient has bleeding in the brain or other abnormalities in the brain, as stated by Filler et al. (2019, February). Laboratory tests are not necessary for the majority of patients who present with headache; however, tests are necessary for the diagnosis of certain conditions that present with headache as well as those that are emergent. Neuroimaging studies, such as a head CT scan and an MRI, are often performed on patients who are suffering from headaches. The lumbar puncture and CSF analysis, the erythrocyte sedimentation rate test, and the full blood count are also very important tests. These tests can be utilized to arrive at an accurate diagnosis of a primary headache or a type of secondary headache as well as the underlying cause of the secondary headache.
Find at least five different conditions that could be relevant to the patient’s diagnosis so that a differential diagnosis can be performed.
A sinus headache is characterized by a pressing sensation around the eyes, cheek, and forehead, as stated by Hutchinson (2016).
Migraine headache is a type of headache condition in which the patient suffers from severe headaches that come and go in waves.
Cluster headaches are the most common type of headache disorder that are associated with trigeminal autonomic cephalgia. Cluster headaches are most common in young men.
Tension headaches are characterized by a lack of associated symptoms, which leads medical professionals to refer to them as “featureless headaches.” Although tension headaches occur in episodes, they rarely interfere with day-to-day activities.
Idiopathic stabbing headache is a type of headache that is characterized by pain that is sharp, brief, but severe, and it can occur anywhere in the head. This type of headache can be quite debilitating.
References
Gregory, J. (2019). Use of pain scales and observational pain assessment tools in hospital settings. Nursing Standard. doi, 10.
Lee, V. M. E., Ang, L. L., Soon, D. T. L., Ong, J. J. Y., & Loh, V. W. K. (2018). The adult patient with headache. Singapore medical journal, 59(8), 399.
Hutchinson, S. (2016). Sinus headaches.
Filler, L., Akhter, M., & Nimlos, P. (2019, February). Assessment and management of the emergency department headache. In Seminars in neurology (Vol. 39, No. 01, pp. 020-026). Thieme Medical Publishers. CASE STUDY: A 20-year-old male complains of experiencing intermittent headaches.
Grading Criteria
To access your rubric:
Week 9 Assignment 1 Rubric
Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:
Submit your Week 9 Assignment 1 draft and review the originality report.
Submit Your Assignment by Day 6 of Week 9
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example: CASE STUDY: A 20-year-old male complains of experiencing intermittent headaches.
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.
Learning Resources – CASE STUDY: A 20-year-old male complains of experiencing intermittent headaches.
Required Readings (click to expand/reduce)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 7, “Mental Status”This chapter revolves around the mental status Assessment of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms.
·Chapter 23, “Neurologic System”The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 4, “Affective Changes”
This chapter outlines how to identify the potential cause of affective changes in a patient. The authors provide a suggested approach to the Assessment of this type of change, and they include specific tools that can be used as part of the diagnosis.
Chapter 9, “Confusion in Older Adults”
This chapter focuses on causes of confusion in older adults, with an emphasis on dementia. The authors include suggested questions for taking a focused history as well as what to look for in a physical examination.
Chapter 13, “Dizziness”
Dizziness can be a symptom of many underlying conditions. This chapter outlines the questions to ask a patient in taking a focused history and different tests to use in a physical examination.
Chapter 19, “Headache”
The focus of this chapter is the identification of the causes of headaches. The first step is to ensure that the headache is not a life-threatening condition. The authors give suggestions for taking a thorough history and performing a physical exam.
Chapter 31, “Sleep Problems”
In this chapter, the authors highlight the main causes of sleep problems. They also provide possible questions to use in taking the patient’s history, things to look for when performing a physical exam, and possible laboratory and diagnostic studies that might be useful in making the diagnosis.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5)
Note: Download the Physical Examination Objective Data Checklist to use as you complete the Comprehensive (Head-to-Toe) Physical Assessment assignment.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical examination objective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance Center.
Note: Download and review the Student Checklists and Key Points to use during your practice neurological examination.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Mental status: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Bearden , S. T., & Nay, L. B. (2011). Utility of EEG in differential diagnosis of adults with unexplained acute alteration of mental status. American Journal of Electroneurodiagnostic Technology, 51(2), 92–104.
This article reviews the use of electrocenographs (EEG) to Help in differential diagnoses. The authors provide differential diagnostic scenarios in which the EEG was useful.
Athilingam, P ., Visovsky, C., & Elliott, A. F. (2015). Cognitive screening in persons with chronic diseases in primary care: Challenges and recommendations for practice. American Journal of Alzheimer’s Disease & Other Dementias, 30(6), 547–558. doi:10.1177/1533317515577127
Sinclair , A. J., Gadsby, R., Hillson, R., Forbes, A., & Bayer, A. J. (2013). Brief report: Use of the Mini-Cog as a screening tool for cognitive impairment in diabetes in primary care. Diabetes Research and Clinical Practice, 100(1), e23–e25. doi:10.1016/j.diabres.2013.01.001
Roalf, D. R., Moberg, P. J., Xei, S. X., Wolk, D. A., Moelter, S. T., & Arnold, S. E. (2013). Comparative accuracies of two common screening instruments for classification of Alzheimer’s disease, mild cognitive impairment, and healthy aging. Alzheimer’s & Dementia, 9(5), 529–537. doi:10.1016/j.jalz.2012.10.001. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036230/
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:
Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY
Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us
Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)
Document: Student Acknowledgement Form (Word document)
Note: You will sign and date this form each time you complete your DCE Assignment in Shadow Health to acknowledge your commitment to Walden University’s Code of Conduct.
Document: DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment (Word document)
Use this template to complete your Assignment 3 for this week.
Optional Resources – CASE STUDY: A 20-year-old male complains of experiencing intermittent headaches.
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
Chapter 14, “The Neurologic Examination” (pp. 683–765)This chapter provides an overview of the nervous system. The authors also explain the basics of neurological exams.
Chapter 15, “Mental Status, Psychiatric, and Social Assessments” (pp. 766–786)In this chapter, the authors provide a list of common psychiatric syndromes. The authors also explain the mental, psychiatric, and social Assessment process.
Mahlknecht, P., Hotter, A., Hussl, A., Esterhammer, R., Schockey, M., & Seppi, K. (2010). Significance of MRI in diagnosis and differential diagnosis of Parkinson’s disease. Neurodegenerative Diseases, 7(5), 300–318. CASE STUDY: A 20-year-old male complains of experiencing intermittent headaches.
