CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS

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CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS

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.

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RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

  • 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 evaluation 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”Download 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 evaluation 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”Download 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”Download 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”Download 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”Download 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. CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS
  • 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)

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

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.

About 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.

Week 9 Assignments

All Sections

This week you will need to complete Your Physical Exam Requirement in Shadow Health. Please spend as much time as possible on this as it is a requirement to pass this to pass the course.

For your case presentation please pick one of these cases:

 

Case Study 1: Facial Droop

22-year-old African American female looks in the mirror and notices the left side of her mouth is slanted when she smiles. She notes she has had some headache off and on a few days. Her taste has decreased as well when she started brushing her teeth.  CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS

Case 2: Forgetfulness

Asia brings her 67-year-old father into the office stating he is very forgetful. He has lost his car keys several times. She also states he has driven to the store and called her asking for directions to get back home. 

 

I WILL GO WITH CASE STUDY 2

Case 2: Forgetfulness

Asia brings her 67-year-old father into the office stating he is very forgetful. He has lost his car keys several times. She also states he has driven to the store and called her asking for directions to get back home. 

Week 9

Shadow Health Comprehensive SOAP Note Template

 

Patient Initials: _______                 Age: _______                                   Gender: _______

 

 

SUBJECTIVE DATA:

 

Chief Complaint (CC):

 

History of Present Illness (HPI):

 

Medications:

 

Allergies:

 

Past Medical History (PMH):

 

Past Surgical History (PSH):

 

Sexual/Reproductive History:

 

Personal/Social History:

 

Health Maintenance:

 

Immunization History:

 

Significant Family History:

 

Review of Systems:

 

General:

            HEENT:

            Respiratory:

            Cardiovascular/Peripheral Vascular:

            Gastrointestinal:

            Genitourinary:

            Musculoskeletal:

            Neurological:

            Psychiatric:

            Skin/hair/nails: CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS

 

 

OBJECTIVE DATA:

 

Physical Exam:

Vital signs:

General:

HEENT:

Neck:

Chest/Lungs:.

Heart/Peripheral Vascular:

Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

 

Diagnostic results:

 

ASSESSMENT:

 

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses. CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS