Make A SOAP Note Not A Narrative Essay: Assessing Neurological Symptoms
Make A SOAP Note Not A Narrative Essay: Assessing Neurological Symptoms
Make A SOAP Note Not A Narrative Essay: Assessing Neurological Symptoms
Patient Information:
Initials: JH Age: 33 years old Sex: Female Race: Hispanic
S.
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CC: “The right side of my face has been dropping since morning.”
HPI: JH is a 33-year-old Hispanic female who came to the hospital complaining of her right face ‘drooping.’ She claims that the feeling started in the morning on the same day that she came to the hospital. She also complains of excessive tearing and drooling on the whole of her right side. She is however in no pain.
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Location: right side of the face
Onset: in the morning
Character: drooping face
Associated signs and symptoms: excessive tearing and drooling on her right side
Timing: In the morning
Exacerbating/ relieving factors: none has been mentioned
Severity: not specified
Current Medications: None
Allergies: No known allergies to drugs, food or any environmental factor.
PMHx: No history given. No surgical history.
Soc Hx: Occupational and major hobbies in addition to family status has not been provided.
Fam Hx: Family history has not been provided.
ROS:
GENERAL: Denies weight loss, chills, fever, fatigue or general weakness.
HEENT: Eyes: Confirms excessive tearing. Denies visual loss, double vision, blurred vision, or yellow sclerae. Ears, Nose, Throat: Denies, hearing loss, congestion, sneezing, sore throat or runny nose.
SKIN: Denies itching or skin rash
CARDIOVASCULAR: Denies chest pain, chest discomfort or chest pressure. No edema or palpitations.
RESPIRATORY: Denies breathing problems, shortness of breath, sputum or cough. No shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies nausea or vomiting, diarrhea or anorexia. Denies abdominal pain or bleeding.
GENITOURINARY: Denies burning on urination, painful urination or excessive urine frequency.
NEUROLOGICAL: Confirms drooping of the right side of the face. Confirms drooling on her right side. Denies headache, syncope, dizziness, ataxia, paralysis. Denies any change in bladder or bowel control.
MUSCULOSKELETAL: Denies muscle or joint pain or stiffness.
HEMATOLOGIC: Denies bleeding, bruises or history of anemia.
LYMPHATICS: Denies enlarged lymph nodes or any history of organomegaly.
PSYCHIATRIC: Denies any history of anxiety, depression or mania.
ENDOCRINOLOGIC: Denies excessive sweating, excessive cold or heat intolerance. Denies polydipsia or polyuria.
ALLERGIES: Denies any history of asthma attacks, eczema, hives, rhinitis or any allergic reactions.
O.
Physical exam:
GENERAL: The patient is fatigued with general body weakness. Fever & chills are also present. No weight gain or weight loss.
HEAD: Her head is normocephalic and atraumatic with no injury
EENT: Eyes: white sclera, pinkish conjunctiva, no jaundice or pallor. Presence of excessive tearing in the right eye, no movement on the eyebrows, eyelid opening is normal; lower lid is sagging. Ears, Nose, Throat: No hearing problems, sneezing, running nose, sore throat or congestion. The nasolabial fold is absent on the right side. Presence of drooling on her right side, no movement of lips and mouth slightly open on the left side.
SKIN: Normal warm skin with no lesions, itching or dryness.
CARDIOVASCULAR: No murmurs. Heart rhythm and heart rate is normal, with good S1 &S2 sound and no S3 & S4. No signs of peripheral edema.
RESPIRATORY: No breathing problems, respiration is even and unlabored. No cough, sputum or shortness of breath.
GASTROINTESTINAL: soft abdomen with no tenderness on palpation. Presence of bowel sounds in all of the four quadrants.
NEUROLOGICAL: Paralysis of the right facial nerve.
MUSCULOSKELETAL: ROM, no joint pain, back pain or stiffness.
LYMPHATICS: No signs of enlarged lymph nodes.
Diagnostic results: unilateral, single episodes that involve all the nerve branches is an indication of Bell’s palsy. Consequently, studies show that unequal distribution of weakness on different zones of the face on physical examination suggests Bell’s palsy (Eviston et al., 2015). This condition occurs at any age above two years, but most commonly experienced by individuals between the age of 15 to 45 years. It is also important to check for the presence or absence of other associated symptoms such as dry eyes, synkinesis, and pain to be able to rule out other differential diagnoses. From the physical examination, the patient is suspected of having an acute unilateral facial palsy which is a significant indication of Bell’s palsy. Other imaging tests such as needle electromyography (EMG), CT scan, and MRI are necessary for ruling out other conditions with the same symptoms (Wiggins, & Ashok, 2015). Serological test for Borrelia Burgdorferi should also be requested, such that a negative result will indicate bell’s palsy as a possible diagnosis.
A.
Differential Diagnoses:
- Bell’s Palsy: Bell’s palsy is a neurological condition characterized by an acute unilateral palsy of the peripheral facial nerve. The diagnosis of this condition is normally confirmed in patients of whom medical history and physical examination are unremarkable, including deficits that affect all the zones of the face equally, and fully resolve within three days. Bell’s palsy leads to a sudden weakness of the facial muscles temporarily, which makes one side of the face to droop (Eviston et al., 2015). The patient in the assigned case scenario is positive for most of the indicating signs and symptoms of Bell’s palsy making this condition the most appropriate diagnosis.
- Lyme disease: This is a bacterial infection that is transmitted by a vector, infected black-legged tick which is commonly referred to as the deer tick. Prolonged infection causes injury to the neurological system that may present as paralysis on one side of the face, weakness in both limbs, numbness, and impaired movement of muscles (Wormser et al., 2015).
- Facial nerve schwannoma: This is a type of a primary benign intracranial tumor of the vestibular nerve of the myelin-forming calls. The main sign and symptoms of this condition is the slow progression of facial nerve paralysis which causes drooping of the face, which the patient in this case study is positive for (Slattery, 2014). Additional symptoms include hearing loss, vestibular symptoms, pain, and tinnitus.
- Idiopathic orofacial granulomatosis (Melkersson-Rosenthal syndrome): This condition is characterized by insidious and slowly progressive paralysis of the facial nerve. The parotid mass is usually palpable upon physical examination (Miest et al., 2017).
- Cerebrovascular accident (CVA): This condition is commonly known as stroke, and it is caused by blockage or rupture of blood vessels supplying blood to the brain. It is characterized by numbness and paralysis in the face which the patients positive for, among other symptoms (Karliński, Gluszkiewicz, & Członkowska, 2015). These symptoms include difficulty in walking, loss of balance and coordination, dizziness, blurred or darkened vision, a sudden headache that is accompanied by nausea and vomiting and difficulty in speaking.
References
Eviston, T. J., Krishnan, A. V., Croxson, G. R., Kennedy, P. G. E., & Hadlock, T. (December 01, 2015). Bell’s palsy: Aetiology, clinical features, and multidisciplinary care. Journal of Neurology, Neurosurgery, and Psychiatry, 86(12), 1356-1361.
In Slattery, W. H. (2014). The facial nerve. New York, NY: Thieme.
In Wiggins, R. H., & In Ashok, S. (2015). Head and neck imaging. Philadelphia, PA: Elsevier.
Karliński, M., Gluszkiewicz, M., & Członkowska, A. (January 01, 2015). The accuracy of prehospital diagnosis of acute cerebrovascular accidents: an observational study. Archives of Medical Science, 11(3), 530-535.
Miest, R. Y., Bruce, A. J., Comfere, N. I., Hadjicharalambous, E., Endly, D., Lohse, C. M., & Rogers, R. S. (January 01, 2017). A Diagnostic Approach to Recurrent Orofacial Swelling: A Retrospective Study of 104 Patients. Mayo Clinic Proceedings, 92(7), 1053-1060.
Wormser, G. P., Weitzner, E., McKenna, D., Nadelman, R. B., Scavarda, C., & Nowakowski, J. (January 01, 2015). Long-term assessment of fatigue in patients with culture-confirmed Lyme disease. The American Journal of Medicine, 128(2), 181-4.
Make a SOAP Note Not a narrative essay: Assessing Neurological Symptoms
Note: Your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to the Comprehensive SOAP Template in the attachments below for guidance.
CASE: Numbness and Pain
A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools.
To prepare:
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.
Address all these in the SOAP Note not an Narrative Essay (Follow the SOAP Note Template on the attachment):
1. A description of the health history you would need to collect from the patient in the case study to which you were assigned.
2. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.
3. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
REMINDER:Please make a SOAP NOTE for this case. Make your own patient’s data, applicable health history, review of systems, P.E., labs, differential diagnosis, final diagnosis etc. Incorporate the data from the case in the SOAP note that you will do… This is not a narrative essay ok…. I need SOAP note (Nurse Practitioner/RN/MD makes SOAP note)… Be guided with the SOAP Note in the template… Don’t copy paste. Formulate your own… Don’t forget to cite the Five Differential diagnosis and have Reference lists too. Rank the differential diagnosis from most to least likely… Expand more your ideas in explaining the diagnosis not only one or two sentences. Justify them correctly and briefly.
Resources:
· Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
o Chapter 5, “Mental Status” (64-78)
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.
o Chapter 22, “Neurologic System” (pp. 544-580)
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. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
o Chapter 4, “Affective Changes” (pp. 33-46)
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.
o Chapter 9, “Confusion in Older Adults” (pp. 97-109)
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.
o Chapter 13, “Dizziness” (pp. 148-157)
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.
o Chapter 19, “Headache” (pp. 221-234)
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.
o Chapter 28, “Sleep Problems” (pp. 345–355)
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. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
o Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”; p. 26)
o Chapter 3, “Adult Preventative Care Visits” (“Assessing Geriatric Risk Factors”; pp. 50–55)
o Chapter 4, “Pediatric Preventative Care Visits” (” Neurological Reflexes Tthat Should Be Tested During Infancy”; (p. 79)
o Chapter 10, “Prescription Writing and Electronic Prescribing” (pp. 207–-223)
Note: Download and review these Adult Examination Checklists and Physical Exam Summary to use during your practice neurological examination.
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for mental assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Mental Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for neurologic assessment. In Mosby’s guide to physical examination(7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Neurologic Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Neurologic system. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Neurologic System Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· 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 assist in differential diagnoses. The authors provide differential diagnostic scenarios in which the EEG was useful.
· Lonie, J. A., Tierney, K. M., & Ebmeier, K. P. (2009). Screening for mild cognitive impairment: A systematic review. International Journal of Geriatric Psychiatry, 24(9), 902–915.
This study seeks to review the use of cognitive screening instruments for mild cognitive impairment. The authors also discuss the limitations of cognitive screening instruments.
· University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved fromhttp://www.med-ed.virginia.edu/courses/rad/index.html
This website provides an introduction to radiology and imaging. For this week, focus on head CTs in neuroradiology.
Media
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 5 and 22 that relate to the assessment of cognition and the neurologic system. Refer to the Week 4 Learning Resources area for access instructions.
Optional Resources
· LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowin’s diagnostic examination (9th ed.). New York, NY: McGraw Hill Medical.
o 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.
o Chapter 15, “Mental Status, Psychiatric, and Social Evaluations” (pp. 766–786)
In this chapter, the authors provide a list of common psychiatric syndromes. The authors also explain the mental, psychiatric, and social evaluation 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.
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