Assignment: Assessing Neurological Symptoms Walden University

Assignment: Assessing Neurological Symptoms Walden University

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.

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In this Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

To Prepare
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:

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 1 Assignment- Case Study- Assessing Neurological Symptoms

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 be making up the information that is missing to complete this soap note.
***Below is the case study to use for this assignment:***
Case Study 3: 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.

ORDER A CUSTOMIZED, PLAGIARISM-FREE HERE ON: Assignment: Assessing Neurological Symptoms Walden University

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

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:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies 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)

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7^th edition formatting.

Assessing Neurological Symptoms

SUBJECTIVE DATA

Chief Complaint (CC): Left sided facial droop and reduced sense of smell.

History of Present Illness (HPI):

NM, a 22-year-old African American woman, visited the clinic because she was concerned about a slanting of her left side of the mouth when she smiled. She reports that when she smiles, the left side of her mouth is angled, and she realized this when she woke up today and looked in the mirror. She said that she had been suffering from headaches on and off for the last several days, and that since she had begun cleaning her teeth, her sense of taste had also diminished.

Medications: None

Allergies: NKA

Past Medical History (PMH): Asthma

Past Surgical History (PSH): Denies past surgeries

Sexual/Reproductive History: Menarche age 13. Heterosexual. LMP 4 weeks ago

Personal/Social History:  Denies tobacco, alcohol or illicit drug use. Reports eating a healthy diet and exercises 4-5 times a week.

Immunization History: immunizations up to date.  Flu shot not current.

Significant Family History:

Father – diabetes

Mother – high cholesterol

Sister – Healthy

Review of Systems (ROS)

General: Denies fever, headache, chills or night sweats. Denies fatigue or recent weight loss.

Cardiovascular/Peripheral Vascular: Denies chest pain, edema, or palpitations.

Respiratory: Denies shortness of breath, cough, or wheezing.

Neuro: Denies dizziness, headaches, or vertigo

Psych: Denies anxiety or depression

OBJECTIVE DATA

Physical Exam:

Vital signs: BP 118/79, HR 78, RR 16, Temp 37. 1 C, SpO2 98%, Ht. 5ft 3in, Wt 146, BMI 23.6.

General: alert and oriented x3. Left facial droop noted. Well-dressed with appropriate grooming. Clear and coherent speech.

HEENT:  Normocephalic and atraumatic head.  Left facial droop noted. Intact visual acuity, PERRLA. TMS pearly grey and intact. Nasal mucosa is moist and pink. Pink pharynx, no edema or exudates.

Skin: Skin is warm and dry, no rash or lesions

Cardiovascular/Peripheral Vascular: S1, S2 clear to auscultation, no gallops, rubs, or murmurs. No edema

Respiratory: Lung sounds clear to auscultation, no cough or wheeze

Neurological: Positive for paresis on left side of face. DTR’s intact. CN II – XII grossly intact.

Diagnostic Test/Labs:

·       CBC

·       Electroneurography/EMG

·       MRI and CT scan

• NIH Stroke Scale

ASSESSMENT:

Differential diagnosis

 

• Bell’s Palsy: This is a disorder in which the muscles on one side of the face experience abrupt and severe weakening. The weakening gives the appearance that half of the face is sagging (Somasundara & Sullivan, 2017). When someone smiles, just one side of their mouth moves, and the eye on the unmoved side resists shutting.
• Guillain-Barre Syndrome: This condition is characterized by the immune system of the body attacking the nervous system. Typically, the first symptoms to appear are a feeling of numbness and weakness in the hands and feet. These feelings may swiftly spread throughout the body and possibly paralyze it completely (Andary, 2017).
• Stroke: This disorder manifests itself either when a blood artery in the brain bursts and bleeds, or when there is an obstruction in the blood flow that leads to the brain. Blood and oxygen are unable to reach the tissues of the brain because of the rupture or the obstruction. A stroke results in facial drooping and partial facial paralysis, and also drooping of the eyes and lips (Alwood & Dossani, 2020).
• Lyme disease: Facial palsy may be caused by an infection that is transmitted by a tick bite. Lyme disease is characterized by a unique skin rash, as well as other symptoms such as fever, headache, and weariness (Cardenas-de la Garza et al., 2018). Eventually, the illness will move to the nerves.
• Hemiplegic migraine: This uncommon kind of migraine may induce temporary paralysis on one side of the body, as well as weakness, tingling, and numbness on the affected side of the body (Kumar et al., 2018).

References

Alwood, B. T., & Dossani, R. H. (2020). Vertebrobasilar Stroke. In StatPearls [Internet]. https://europepmc.org/books/nbk556084

Andary, M. (2017). Guillain-Barre Syndrome. https://emedicine.medscape.com/article/315632-overview

Cardenas-de la Garza, J. A., De la Cruz-Valadez, E., Ocampo-Candiani, J., & Welsh, O. (2018). Clinical spectrum of Lyme disease. European Journal of Clinical Microbiology & Infectious Diseases, 38(2), 201-208. https://doi.org/10.1007/s10096-018-3417-1

Kumar, A., Samanta, D., Emmady, P. D., & Arora, R. (2018). Hemiplegic migraine. https://europepmc.org/books/nbk513302

Somasundara, D., & Sullivan, F. (2017). Management of Bell’s Palsy. Australian Prescriber, 40(3), 94-96. https://doi.org/10.18773/austprescr.2017.030