FYI: Document in Focus note format, you will need to make up information to complete SOAP note.
You must make up information to complete SOAP NOTE
Provide a Comprehensive Assessment of Affected System
Assignment 1: Case Study Assignment: Assessing Neurological Symptoms
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:
Forgetfulness
A 70-year-old female comes to your clinic with complaints of forgetfulness. She noticed it about a year ago and it has progressively gotten worse. She sometimes forgets what she is going to do when she gets to another room. Her family has noticed the problem with her forgetfulness but she is still able to manage her finances and drive, per her report.
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.
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Please keep in mind that you will need to make up information to complete the SOAP note if you document in Focus note style.
To finish SOAP NOTE, you must make up information.
Provide a Comprehensive Assessment of the Affected System
Case Study is the first assignment. Examining Neurological Symptoms is an assignment.
Consider not being able to create new memories. This is the reality that patients suffering from anterograde amnesia face. Although this type of amnesia is uncommon, it can occur as a result of severe brain trauma. Anterograde amnesia exemplifies how detrimental brain illnesses may be to a patient’s quality of life. 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
