Assignment 1: Case Study Assignment: Assessing Neurological Symptoms NURS 6512N-32
Assignment 1: Case Study Assignment: Assessing Neurological Symptoms NURS 6512N-32
Assignment 1 Case Study Assignment Assessing Neurological Symptoms NURS 6512N-32
Episodic/Focused SOAP Note
Patient Information:
Initials: J.K.L
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Age: 40 years
Sex: Female
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Race: African American
Source: Patient
S.
CC: “I have a headache around my forehead.”
HPI: J.K.L is a 40-year-old African American female who presents with a complaint of a headache across her forehead for a week. The headache is squeezing and feels like pressure behind the eyes. It is non-radiating. The headache is constant and varies in severity ranging from 2/10 at its best to 8/10 at its worst. It is usually worse in the morning and while bending. Acetaminophen reduces the severity of the headache to 4/10 and occasionally 2/10. It is associated with fever, postnasal drip, nasal congestion, sneezing, and occasional non-productive cough. She takes Sudafed HCL 120 mg every 12 hours to obtain some relief. The symptoms have significantly impaired her concentration at work and made her feel very tired. Finally, she reports a head cold three weeks ago.
Current Medications: Pseudoephedrine 120 mg BID for nasal congestion and acetaminophen for headaches.
Allergies: She has no known food and drug allergies.
Past Medical History: During her last visit to the primary care physician 2 months ago, she was noted to be prehypertensive and was advised on lifestyle modifications. No prior hospitalization. No previous surgeries or blood transfusions.
Social History: She is married with two children both alive and well. She works as a secretary Her husband is a college teacher. She neither drinks alcohol nor smokes tobacco. She does not use marijuana or other illicit drugs. She strictly adheres to dietary advice from her nutritionist and she exercises regularly. Denies caffeine intake.
Family History: Her father is alive and well at the age of 60, suffering from hypertension, while her mother is alive and well at the age of 58. Her brother and sister, who are 35 and 20 years old, are both alive and well. Her paternal grandfather died of a heart attack at the age of 80, and her paternal grandmother is 78 and hypertensive. Her maternal grandfather is 77 years old and has a history of type 2 diabetes and high cholesterol, while her maternal grandmother died of a stroke at the age of 70. There is no family history of cancer, mental illness, asthma, sickle cell disease, or diabetes.
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A.
Differential Diagnosis:
1) Diabetic neuropathies- given that the patient has a history of diabetes and that the condition is caused by the metabolic disorder hyperglycemia, which results in impaired insulin secretion, this diagnosis seems conceivable. This syndrome gives rise to the clinical signs that the patient presents with, including tingling and numbness (McCance & Huether, 2019).
2) Hypothyroidism- considering that the patient’s tingling sensation and weight gain were clinical signs of low levels of thyroid hormone, likely resulting from a thyroid gland abnormality (Agency for healthcare research and quality, 2016).
3) Alcohol associated neuropathy- given that the patient recalls using alcohol and that numbness is
one of the condition’s clinical symptoms, it is possible that this is the cause of the loss of feeling in part of the nerves (McCance & Huether, 2019).
4) Guillain-Barre syndrome-is a disorder where the body’s immune system targets the nerves. The patient reported feeling tingling in their hands and possibly elevated blood pressure, therefore this is a reasonable diagnosis (McCance & Huether, 2019).
5) Vitamin B-12 deficiency- this illness is caused by the body having less vitamin B-12 than usual, which may result in clinical symptoms like the numbness the patient has reported (Agency for healthcare research and quality, 2016).
Primary Diagnosis: Diabetic neuropathies
References
McCance, K. L., Huether, S. E., BRASHERS, V. L., & ROTE, N. S. (2019). Pathophysiology: The biologic basic for diseases in adults and children (No. ed. 8). Elsevier
Petropoulos, I. N., Ponirakis, G., Khan, A., Almuhannadi, H., Gad, H., & Malik, R. A. (2018). Diagnosing diabetic neuropathy: something old, something new. Diabetes & metabolism journal, 42(4), 255.
YEAR, F. (2016). Agency for healthcare research and quality.
ROS:
GENERAL: Reports fatigue and occasional fever. Denies weight loss, night sweats, and chills.
HEENT: Reports headaches, nasal congestion, post nasal drip, and sneezing. No blurring of vision, visual loss, hearing loss, tinnitus, nose bleeds, ear pain, mouth sores, or sore throat.
SKIN: no skin lesion or rashes. No abnormal pigmentation.
CARDIOVASCULAR: Negative for palpitations, chest pain, paroxysmal nocturnal dyspnea, and peripheral limb edema.
RESPIRATORY: Occasional non-productive cough. No difficulty in breathing, dyspnea, or orthopnea.
GASTROINTESTINAL: Reports loss of appetite and occasional nausea and vomiting. Denies change in bowel habits, abdominal pain, or distention.
GENITOURINARY: No frequency, dysuria, nocturia, and polyuria. No vaginal itchiness or abnormal vaginal discharge.
NEUROLOGICAL: Reports headache. Denies dizziness, lightheadedness, numbness, tingling, loss of sensation, syncope, and convulsion.
MUSCULOSKELETAL: No muscle pain, joint pains, muscle weakness, or muscle swelling.
HEMATOLOGIC: No anemia, easy bruising, or bleeding.
LYMPHATICS: Normal lymph nodes
PSYCHIATRIC: Denies anxiety, depression, suicidal ideations, or hallucinations.
ENDOCRINOLOGIC: Denies heat or cold intolerance, polyphagia, and polydipsia.
ALLERGIES: Reports no allergies.
O.
Physical exam:
VITAL SIGNS: BP 125/78 mmHg, HR 88 b/min, Temp 99. 8 F, RR 20 b/min, saturation 95% on room air, Height 168 cm, weight 76 Kg. Pain level 5/10
GENERAL: A middle-aged African-American female, well kempt, not in any form of respiratory distress but slight discomfort. Maintains eye contact, coherent speech, and a stable mood. Well-hydrated and nourished. No palmar or conjunctival pallor, jaundice, central or peripheral cyanosis, cervical or inguinal lymphadenopathy, and peripheral limb edema.
HEENT: Head is normocephalic and atraumatic. Scalp is not tender. Pink conjunctiva and white sclera on both sides of the eyes. Pupils react to light equally and bilaterally, with no ptosis or lid edema. Extraocular movements are normal. Bilateral ears are present, there is no impaction or skin lesions, the tympanic membrane is pearly grey on both sides, and there is a positive white reflex. Both nares are present and discharging mucus, as well as a midline nasal septum and pink and soft nasal mucosa. Maxillary and frontal sinuses are tender. There are no oral lesions or ulcers, and the oral mucosa is moist and pink. Dentition and tooth alignment are normal.
NECK: Soft neck. The trachea is central. Full range of motion, non-tender, no cervical lymphadenopathy, and no thyroid enlargement.
CARDIOVASCULAR: Regular heart rate. Normoactive precordium. Point of maximal impulse in the 5th intercostal space in the midclavicular line. S1 and S2 head, no murmurs, thrills, gallops, rubs, or heaves.
RESPIRATORY: Symmetrical chest that moves with respiration. No scars or skin lesions. Equal chest expansion and equal tactile fremitus bilaterally. Equal air entry, vesicular breath sounds, no wheezes, and crackles, and equal vocal fremitus in all lung zones.
NEUROLOGICAL: GCS 15/15, oriented to time, place, and person, intact short-term and long-term memory, good concentration, and a clear coherent speech. Cranial nerves 1 to 12 intact. Normotonic across all joints, normal bulk, and power 5/5 across all muscle groups in upper and lower extremities, deep tendon reflexes 2+ and equal bilaterally in upper and lower limbs. Intact monofilament sensation across all dermatomes, good bowel, and bladder function. No spinal tenderness, normal gait, coordination, graphesthesia, and stereognosis. Normal finger nose, heel to the shin, and rapid alternating movements tests.
Diagnostic results:
J.K.L appears to have an inflammatory/infectious condition. Consequently, complete blood count and inflammatory markers particularly CRP and ESR are paramount. Similarly, bacterial or fungal cultures obtained endoscopically or by direct sinus aspiration are required to identify the possible pathogen. Additionally, a skin prick test is essential to exclude allergic rhinitis. Imaging modalities principally Sinus CT and MRI are recommended to evaluate for rhinosinusitis and intraorbital or intracranial involvement
A.
Differential Diagnoses
Acute Sinusitis- refers to the inflammation of sinuses lasting less than 4 weeks (DeBoer & Kwon, 2022). The condition is more common in females and particularly during early fall to early spring (DeBoer & Kwon, 2022). It is most commonly caused by viral infection following a common cold although bacteria and fungi are not uncommon etiologies. J.K.L presents with clinical features that are typical of acute sinusitis including fatigue, fever, headache, facial pain, and pressure worse on bending (DeBoer & Kwon, 2022). Maxillary sinuses and frontal sinuses appear to be the affected sinuses in her as evidenced by pain around the forehead and tenderness of the maxillary and frontal sinuses (DeBoer & Kwon, 2022).
Rhinitis- Refers to the inflammation of the nasal mucosa. J.K.L presents with clinical manifestations suggestive of rhinitis including sneezing, nasal congestion, postnasal drip, and rhinorrhea (Liva et al., 2021). Similarly, she reports a “head cold” three weeks ago. Rhinitis is mostly caused by an upper respiratory infection or type 1 hypersensitivity reaction (Liva et al., 2021). However, an upper respiratory tract infection is likely the cause in her case.
Cluster headache- Cluster headache is a type of primary headache that is usually unilateral retro-orbital and characterized by sharp and stabbing pain (Goadsby et al., 2018). Cluster headache may present with symptoms of lacrimation, nasal congestion, rhinorrhea, ptosis, or miosis (Goadsby et al., 2018). However, it is unlikely the diagnosis in her as cluster headache usually lasts for a brief period. Similarly, cluster headaches mostly awake the patient at night.
Migraine headache- Migraine headache is another type of primary headache that may be preceded with or without aura. It is usually pulsating and moderate to severe (Pescador Ruschel & O, 2022). It is common in young women. However, it is unlikely the diagnosis as migraines last 4 to 72 hours if untreated and are typically associated with nausea, vomiting, photophobia, and phonophobia (Pescador Ruschel & O, 2022).
Rebound headache– Commonly referred to as medication overuse headache. Rebound headache predominantly occurs in individuals with primary headaches who overuse analgesia (Micieli & Robblee, 2018). Rebound headaches are more common in females and individuals less than 50 years. Drugs precipitating this headache include barbiturates, acetaminophen, opioids, ergotamine, and triptans (Micieli & Robblee, 2018). However, this is an unlikely diagnosis in J.K.L as a diagnosis of primary headache hasn’t been established.
References
DeBoer, D. L., & Kwon, E. (2022). Acute Sinusitis. https://pubmed.ncbi.nlm.nih.gov/31613481/
Goadsby, P., Wei, D.-T., & Yuan Ong, J. (2018). Cluster headache: Epidemiology, pathophysiology, clinical features, and diagnosis. Annals of Indian Academy of Neurology, 21(5), 3. https://doi.org/10.4103/aian.aian_349_17
Liva, G. A., Karatzanis, A. D., & Prokopakis, E. P. (2021). Review of rhinitis: Classification, types, pathophysiology. Journal of Clinical Medicine, 10(14), 3183. https://doi.org/10.3390/jcm10143183
Micieli, A., & Robblee, J. (2018). Medication-overuse headache. Journal de l’Association Medicale Canadienne [Canadian Medical Association Journal], 190(10), E296–E296. https://doi.org/10.1503/cmaj.171101
Pescador Ruschel, M., & O, D. J. (2022). Migraine Headache. https://pubmed.ncbi.nlm.nih.gov/32809622/
A 63-year-old woman arrives at your office because she has been forgetting things… A young mother arrives worried because her baby isn’t making eye contact and is unresponsive to touch… A teen walks in, and his parent complains that he washes his hands obsessively.
The above symptoms could be caused by a variety of neurological conditions. When evaluating the neurologic system, it is critical to arrive at an accurate diagnosis as soon as possible in order to prevent further damage and deterioration of a patient’s quality of life.
This week, you will investigate methods for evaluating 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
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.
Assignment 1: Case Study Assignment: Assessing Neurological Symptoms NURS 6512N-32
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.You will consider case studies that depict aberrant results in individuals observed in a clinical environment in this Case Study Assignment.To Get Ready
You will be allocated to a specific case study for this Case Study Assignment by Day 1 of this week. Please see the “Course Announcements” section of the classroom for your Instructor’s assignment.
In addition, rather than the typical narrative style structure, your Case Study Assignment should be in the Episodic/Focused SOAP Note format. For further information, see Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources. Remember that all Episodic/Focused SOAP notes include specific data for each patient instance. - https://nursingmasters.blog/assignment-1-case-study-assignment-assessing-neurological-symptoms-nurs-6512n-32/Examine this week’s Learning Resources and think about the insights they offer concerning the case study.
Consider what information you would need to obtain from the patient in the case study you were given.
Consider what physical exams and diagnostic testing might be necessary to learn more about the patient’s condition. How would the findings be used to make a decision?
Identify at least five probable conditions that could be considered in the patient’s differential diagnosis.
The Case Study ProjectCreate 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 literary evidence to support diagnostic testing that would be appropriate in each scenario. Explain why you chose each of the five probable conditions for the patient’s differential diagnosis.
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Episodic/Focused SOAP Note Focused SOAP Note for a patient with complains of numbness and tingling sensation. S. HPI: The patient is a 48-year-old Caucasian male who has come into the health facility due to complains of not being able to feel the toes on the left foot and also numbness in the heel of the right foot that is accompanied with a tingling sensation. The clinical manifestations started four days ago and patient reports they are aggravated when he is lying or siting down. Medications: Oral 1000mg metformin taken twice daily Oral 4mg glimepiride taken twice daily Oral 45mg actos taken four times daily Oral 20mg Lisinopril taken four times daily PMH: Patient is suffering from diabetes mellitus type 2 and is a known hypertensive with also seasonal allergic rhinitis FH: Maternal grandfather: hypertension Father: type 1 diabetes. Brother:asthma SH: Patient lives with his wife and two children Patient used to take tobacco but stopped 10 years ago Patient is employed as a banker Patient drinks alcohol over the weekend Allergies: Patient has seasonal allergies Immunizations: Patient is up to date with his immunizations ROS HEENT- patient has no pain in the nose, ear or eyes. Musculoskeletal– patient has a tingling sensation in the heel of his right foot that is also numb. Patient has numbness in his left toes. Neurological- patient has numbness in his left toes and heel of right foot accompanied by a tingling sensation. Dermatological– patient has nor rash on his body. Endocrine– patient has increased thirst. O. Vitals: Blood pressure-112/90; Pulse-111; Respiration rate-24; Temperature- 96.0; 0xygen saturation- 99% Weight-240lbs; Height -6‘9
A. Differential Diagnosis: 1) Myocardial Infarction (provide supportive documentation with evidence based guidelines). 2) Angina (provide supportive documentation with evidence based guidelines). 3) Costochondritis (provide supportive documentation with evidence based guidelines). Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
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General- patient is alert and oriented as well as being well-groomed.
Cardiovascular- on auscultation S1 and S2 heard.
Pulmonary- lung sounds are clear on auscultation.
Gastrointestinal—abdomen is without scars or masses and bowel sounds are normoactive, central prominent obesity noted.
Neurological-cranial nerves I-XII are intact. Vibration and proprioception is subnormal in the feet with more of the abnormalities noted in the left foot.
HEENT-head is normocephalic.
Neck and lymph nodes- no enlarged lymph nodes noted.
Skin-capillary refill is less than 3 seconds.
Genitalia- on inspection normal external genitalia noted.
Musculoskeletal- left foot strength is at 2/5 while the other extremities are at 5/5. On touching the feet they are cold.
Diagnostic results: Random blood sugar done to determine the patient’s glucose levels (Petropoulos, et al., 2018).
HbA1c test done to determine glucose levels over a period of two to three months (Petropoulos, et al., 2018).
Urinalysis done to find out whether there are any abnormal values (Petropoulos, et al., 2018).
In order to rule out hypothyroidism a thyroid function test is done (Petropoulos, et al., 2018).
A.
Differential Diagnosis:
1) Diabetic neuropathies- given that the patient has a history of diabetes and that the condition is caused by the metabolic disorder hyperglycemia, which results in impaired insulin secretion, this diagnosis seems conceivable. This syndrome gives rise to the clinical signs that the patient presents with, including tingling and numbness (McCance & Huether, 2019).
2) Hypothyroidism- considering that the patient’s tingling sensation and weight gain were clinical signs of low levels of thyroid hormone, likely resulting from a thyroid gland abnormality (Agency for healthcare research and quality, 2016).
3) Alcohol associated neuropathy- given that the patient recalls using alcohol and that numbness is one of the condition’s clinical symptoms, it is possible that this is the cause of the loss of feeling in part of the nerves (McCance & Huether, 2019).
4) Guillain-Barre syndrome-is a disorder where the body’s immune system targets the nerves. The patient reported feeling tingling in their hands and possibly elevated blood pressure, therefore this is a reasonable diagnosis (McCance & Huether, 2019).
5) Vitamin B-12 deficiency- this illness is caused by the body having less vitamin B-12 than usual, which may result in clinical symptoms like the numbness the patient has reported (Agency for healthcare research and quality, 2016).
Primary Diagnosis: Diabetic neuropathies
References
McCance, K. L., Huether, S. E., BRASHERS, V. L., & ROTE, N. S. (2019). Pathophysiology: The biologic basic for diseases in adults and children (No. ed. 8). Elsevier
Petropoulos, I. N., Ponirakis, G., Khan, A., Almuhannadi, H., Gad, H., & Malik, R. A. (2018). Diagnosing diabetic neuropathy: something old, something new. Diabetes & metabolism journal, 42(4), 255.
YEAR, F. (2016). Agency for healthcare research and quality.
Review of Case Study #1
Patient Information:
Initials: HA
Age: 42 years old
Sex: Male
Race: African American
Subjective
CC (chief complaint) “I have this pain in my lower back for the past month and sometimes I feel the pain in my leg.”
HPI: 42-year-old African American male presents the office with complain of lower back pain for the past month. HA reports the pain started about a month ago as mild tingling with dull aching pain in his lower back but has progressively wors