Assessing Neurological Symptoms Discussion 2
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:
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· 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.
Week 9
A-L CASE STUDY 1: 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.
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
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:
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 Assessing Neurological Symptoms Discussion 2
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) Assessing Neurological Symptoms Discussion 2
Identifying Neurological Symptoms
Forget about making new memories. Anterograde amnesia patients face this reality. Although rare, significant brain trauma can cause this sort of amnesia. Anterograde amnesia exemplifies the impact of brain abnormalities on patients’ lives. Assessing neurological symptoms accurately is a complicated task involving numerous variables.
This Case Study Assignment will examine cases that describe aberrant findings in clinical patients.
Prepared
You will be allocated a case study for this Case Study Assignment by Monday. Your instructor’s assignment is under the “Course Announcements” section of the classroom.
It should be in the Episodic/Focused SOAP Note format, not the usual narrative style. The Episodic/Focused SOAP Template in the Week 5 Learning Resources can help. Remember that all Episodic/Focused SOAP notes contain individual patient data.
Regarding the case study:
ORDER PLAGIARISM-FREE PAPERS NOW! Examine this week’s Learning Resources and their implications for the case study.
Consider what information you would need to get from the patient in your case study.
Determine whatever physical exams and diagnostic testing are necessary to learn more about the patient’s condition. How are the results used to diagnose?
Identify at least five probable conditions in the patient’s differential diagnosis.
The Case Study Task
Create an episodic/focused note about the patient in the case study assigned to you using the episodic/focused note template provided in the Week 5 resources. Cite the literature to support the proper diagnostic tests for each case. List five differential diagnoses for the patient and explain your choices.
9e
STUDY 1: HEADACHES A 20-year-old male has periodic headaches. The headaches are widespread, but the most intense and painful are above the eyes, extending to the nose, cheeks, and jaw.
SOAP Note Template (Episodic)
Patient Info:
Age, sex, race
S.
For example, “headache”, NOT “bad headache for 3 days”.
HPI: This is your symptom analysis part. This section’s documentation is vital for patient care, coding, and billing analysis. Describe the patient’s ailment. Complete HPI using LOCATES Mnemonic. Every HPI needs age, race, and gender (e.g., 34-year-old AA male). The seven qualities of each primary symptom must be written in paragraph form. If the CC was “headache”, the HPI LOCATES might look like this:
Head
3 days ago
pounding, eye and temple pressure
Nausea, vomiting, photophobia, and phonophobia
After a long day at work on the computer
Light troubles eyes, Aleve helps but not fully.
7/10 pain scale Identifying Neurological Symptoms
Incorporate OTC or homeopathic medications into your current medication regimen.
A description of the allergy, e.g. angioedema, anaphylaxis, etc. A real reaction vs intolerance).
For adults, note last tetanus vaccination date, previous significant illnesses, and surgeries. Some CCs require extra information. Soc Occupation and major hobbies; family status; tobacco & alcohol consumption (past & present); and other relevant data Always include a health promotion question here, such as if they always use seat belts or if their home has working smoke detectors.
Fam Hx: genetically predisposed, infectious, or chronic illnesses. Include the cause of death of any first degree relatives. Parents, grandparents, siblings, and kids Include grandkids if relevant.
Cover all body systems that could aid or hinder a differential diagnosis. Listed below are the systems: General: EENT: etc. These should be bulleted and listed from top to toe.
Complete ROS Example:
NO WEIGHT LOSS, FEVER, CHILLS, SLEEP DEPRIVATION
Eyes: No visual loss, double vision, or yellow sclerae. Head, Nose and Throat: No hearing loss, a runny nose and a painful throat.
No rashes or itching.
No chest pain, pressure, or discomfort. No edema or palpitations.
NO COUGH OR SPUTUUM:
No anorexia, nausea, vomiting, or diarrhea. No pain or bleeding.
GENITOURINARY: Urination burns. Pregnancy. Last period, MM/DD/YYYY
CARDIOVASCULAR: No numbness or tingling in the extremities. B/D control remains unchanged.
No muscular, back, joint, or stiffness.
No anemia, bleeding, or bruising.
No swollen lymph nodes. No prior splenectomy.
BRIEF HISTORY OF DEPRESSION OR ANX
No sweating, cold or heat intolerance reported. None of the above.
NO ASTHMA, Hives, Eczema, or Rhinitis.
O.
When performing a physical exam, include everything you see, hear, and feel. Examine only the systems relevant to CC, HPI, and History. No WNL or normal. Observe and describe. Always document from top to bottom i.e. EENT: etc.
Include any tests, x-rays, or other diagnostics needed to make differential diagnosis (support with evidenced and guidelines) Identifying Neurological Symptoms
