NURS 6512: Advanced Health Assessment and Diagnostic Reasoning
Week 9: Assessment of Cognition and the Neurologic System
Cognition and the neurologic system are closely related as cognition refers to the mental processes and abilities that allow us to think, learn, and remember. The neurologic system, which includes the brain and spinal cord, is responsible for controlling and coordinating these cognitive processes. In an advanced health assessment course, cognition and the neurologic system would likely be covered in depth as they are essential components in the assessment of a patient’s overall health. The course may cover topics such as the assessment of cognitive function, including memory, attention, and executive function, and the assessment of the neurologic system, including the examination of cranial nerves, motor function, and reflexes. Additionally, the course may cover the identification and assessment of common neurologic conditions such as stroke, Alzheimer’s disease, multiple sclerosis and traumatic brain injury.
A 63-year-old woman comes to your office because she’s been forgetting things…a young mother comes in concerned because her baby fails to make eye contact and is unresponsive to touch…a teenager comes in and a parent complains that the teen obsessively washes his hands.
An array of neurological conditions could be causing the above symptoms. When assessing the neurologic system, it is vital to formulate an accurate diagnosis as early as possible to prevent continued damage and deterioration of a patient’s quality of life.
This week, you will explore methods for assessing the cognition and the neurologic system.
Learning Objectives
Students will:
Evaluate abnormal neurological symptoms
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for cognition and the neurologic system
Assess health conditions based on a head-to-toe physical examination
Learning Resources
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 http://www.alzheimersanddementia.com/article/S1552-5260(12)02463-6/abstract
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.
Optional Resources
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.
Required Media (click to expand/reduce)
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 7 and 23 that relate to the assessment of cognition and the neurologic system. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/
Assignment 1: Case Study Assignment: Assessing Neurological Symptoms
Photo Credit: Getty Images/iStockphoto
Imagine not being able to form new memories. This is the reality patients with anterograde amnesia face. Although this form of amnesia is rare, it can result from severe brain trauma. Anterograde amnesia demonstrates just how impactful brain disorders can be to a patient’s quality of living. Accurately assessing neurological symptoms is a complex process that involves the analysis of many factors.
In this Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
To Prepare
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 five 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
To submit your completed Assignment for review and grading, do the following:
Please save your Assignment using the naming convention “WK9Assgn1+last name+first initial.(extension)” as the name.
Click the Week 9 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
Click the Week 9 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK9Assgn1+last name+first initial.(extension)” and click Open.
If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
Click on the Submit button to complete your submission
===>
Assessing Neurological Symptoms
Episodic/Focused SOAP Note
Patient Information:
Initials – JM Age – 20 Sex – M Race – White
S.
CC: “Headache spreads all over the head. It spreads to the nose, jaw, and cheekbone. The pain is intensive above the eyes. ”
HPI: A 20-year old white male visits the hospital indicating they have a headache. The patient observes that the pain has been spreading all over the head. The condition began a week ago. The intensity of the headache is high above the eyes. The associated symptom is coughing. The patient observes that the pain starts in the evening after exposure to sunshine. Noise from traffic makes it worse while resting relieves the condition. The patient observes that the pain’s severity is 8 out of 10.
Current Medications: Ibuprofen 800mg OTC daily to relieve the pain and fluticasone propionate 50mcg to relieve seasonal allergic nasal symptoms.
Allergies: No known drug allergies, but allergic to cold, latex and strawberries.
PMHx: All vaccine reports are current including flue, pneumococcal and tetanus vaccines. Diagnosed with asthma in 2017 but taking medication. Left knee cap replacement in 2013.
Soc Hx: The sick person is a local tourist organizer and guide. During his free time, he enjoys reading and playing football. He is heterosexual but single. He says he will wait till marriage to have sex. No smoking, alcohol or ETOH abuse. He wears a seat belt while driving and does not text or call while driving. He is currently living on campus away from his home area. He loves taking caffeinated drinks regularly to fight off sleep.
Fam Hx: The father and mother, 42 and 38 years old respectively, separated two years ago. He lives with his mother while he is on holiday. His father is healthy but his mother has HTN. His grandmother is live and suffering from asthma and HTN. His grandmother died 5 years ago. No siblings and no grandchildren.
ROS:
GENERAL: No weight loss or gain for the last one year. He denies fever, sweating at night or fatigue.
HEENT:
Eyes: Eyes are not sensitive to bright light and no eyeglasses. No double vision or loss of vision. No yellow sclerae.
Ears: No hearing problem, discharge or pain.
Nose: Nasal congestion, sinus pain, seasonal rhinorrhea. No running nose.
Throat: No sore throat, difficulty in speaking or swallowing.
SKIN: No open wounds, itching, bruising or lesions.
CARDIOVASCULAR: No edema, chest pain or chest pressure.
RESPIRATORY: No coughing, sputum, breathing problem or shortness of breath.
GASTROINTESTINAL: The sick person denies any acid reflux, anorexia, vomiting or nausea. No abdominal pain or blood in the stool.
GENITOURINARY: No burning sensation during urination or frequent urination.
NEUROLOGICAL: No numbness, dizziness, ataxia, falling or paralysis. No headache, bladder or bowel control problem.
MUSCULOSKELETAL: No muscle stiffness, pain, joint pain or back pain.
HEMATOLOGIC: The sick person denies bleeding, bruising or bleeding gums.
LYMPHATICS: No enlarged lymph nodes.
PSYCHIATRIC: No anxiety, depression or moody feelings.
ENDOCRINOLOGIC: No heat or cold intolerance, urgent need to urinate or quench thirst. No excessive sweating.
ALLERGIES: The patient observes seasonal allergies, sneezing, and rhinorrhea. No allergies to water, food or drugs.
O.
Physical exam: The data gathered about the health condition of the patient shows they are unwell. The face is pale and the patient has nasal congestion. No excessive tearing observed. The lungs are clear and intact. The sick person says the feeling is similar to having a common cold.
General: BP 120/80, P 87, T 98.7, R 20 Psa02 98% room air.
General information shows that the white male is well dressed. He is alert, aware and oriented, the patient spreads to the jaw, cheekbone, and forehead. It started a week ago. No vomiting or nausea reported.
Head: The neck and head are in full range motion. No lesions or tics noted. Frontal and maxillary palpitations are tender. Ears: No erythema is present. Eyes: Pupil is equal and reactive to light. No excessive tearing. No discharge observed. Nose: Mild rhinorrhea and no bleeding observed. Pale boggy mucosa is observed. Throat: No swollen tonsils or erythema noted. Postnasal drainage is present.
Neck: No masses observed. No webbing or abnormal skinfolds noted. No lymph nodes and the thyroid is palpitated.
Cardiovascular: Regular heart rate, no adventitious sounds observed. No peripheral edema.
Respiratory: Clear lung sounds and no adventitious.
Neurological: Alert and oriented. Regular grip in both hands. Memory is intact both short-term and long-term. The intermittent pain is at 8 out of 10 on a pain scale. No nausea or vomiting.
Diagnostic Results:
The nasal smear is critical while assessing the presence of eosinophil to confirm allergic rhinitis (Rosenfeld, 2016). A radiogram is crucial in assessing the severity of symptoms of the patients. Once the medication is prescribed and it does not respond, a CT scan is needed to check the severity of the condition (Silberstein, 2016). If the condition still persists, an MRI scan is necessary to check the abnormality of brain cells and pathology of soft tissue.
Sinus aspiration is also necessary to check bacterial sinusitis (Goksör et al., 2018). The assessment will require an otolaryngologist who will carry out the endoscopy. The skin will require a test to check for allergic reactions due to the effects when seasons change.
A.
Differential Diagnoses
a) Acute sinusitis
Acute sinusitis is a viral or bacterial inflammation of the membranes in the nose. It hinders free drainage of mucus from the sinuses. The symptoms include headache, nasal congestion, draining mucus in the throat, coughing and pressure above the eyes (Rosenfeld, 2016). The condition may be relieved when the headache and nasal congestion are less intense.
b) Medication rebound headache
Medication rebound headache is a condition associated with the use of drugs or substances such as caffeine. The headache begins after a patient stops taking the medication (Silberstein, 2016). The condition requires further analysis of the medication a patient is taking.
c) Allergic rhinitis
Allergic rhinitis occurs when a patient is exposed to allergens. The symptoms include stuffy nose, watery eyes, sneezing and swollen eyes (Goksör et al., 2018). The diagnosis of the condition requires a physical examination. Tests can only be carried out to rule out non-allergic rhinitis conditions.
d) Rhinitis medicamentosa
The condition is caused by the persistent use of topical decongestants. The only major symptom is the congestion of the nasal drainage (Zucker, Barton & McCoul, 2019). One of the treatments is to stop using a nasal spray for a period of time.
e) Migraine without aura
The condition involves common migraine headaches. The condition does not present early symptoms such as confusion, vision change, weakness or dizziness (Roccella et al., 2019). A thorough examination of medical history is necessary to diagnose the condition.
References
Goksör, E., Wennergren, G., Vasileiadou, S., Mincheva, R., Nwaru, B., Lundbäck, B., & Ekerljung, L. (2018). Increased prevalence of allergic rhinitis in young men in Western Sweden.
Roccella, M., Marotta, R., Operto, F. F., Smirni, D., Precenzano, F., Bitetti, I., … & Salerno, M. (2019). NREM sleep instability in pediatric migraine without aura. Frontiers in Neurology, 10, 932.
Rosenfeld, R. M. (2016). Acute sinusitis in adults. England Med, 375, 962-970.
Silberstein, S. D. (2016). Medication overuse headache. American Headache Society, 12.
Zucker, S. M., Barton, B. M., & McCoul, E. D. (2019). Management of rhinitis medicamentosa: a systematic review. Otolaryngology-Head and Neck Surgery, 160(3), 429-438.
