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 Assessing Neurological Symptoms

Advanced Health Assessment and Diagnostic Reasoning

Assignment 1Case 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.

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 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:

· 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.

· CASE STUDY 2: 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

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 6th edition formatting.

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:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

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

RESPIRATORY:  No shortness of breath, cough or sputum.

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

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

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

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

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

ALLERGIES:  No 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.

P.   

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 6th edition formatting.

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CASE STUDY: Numbness and Pain   

Patient Information:  

CK, 47, Female, Caucasian  

S.  

CC:  numbness and pain in the right wrist  

HPI: 47-year-old Caucasian obese female presents to the clinic with reports of right wrist pain, 6/10 with tingling and numbness in the thumb, index, and middle finger for 2weeks. The patient reports she is a hairdresser for the last 20 years and expressed frustration because the pain causes her to drop her work tools. Pt denies associated signs and symptoms. The patient stated she was at work when the pain, tingling, and numbness occurred, and the pain often wakes her up at night. The patient reports that she usually “shake out” her hand and wear a splint she got over the counter to relieve symptoms. Reports doing several activities with her hand at work causes more pain.    

Current Medications:   

DM type 2, metformin 500mg BID for two years but self-discontinued one year ago, “I didn’t feel I had diabetes.”  

Multivitamin daily for 20 years.    

Allergies: denies medication, food, and environmental allergies   

PMHx: immunization up to date, last tetanus five years ago when she stepped on a nail at work. Diagnosis in 2010 with diabetes type 2. hospitalized last year for pneumonia for three days. No major surgeries past major illnesses and surgeries.   

Soc Hx: works at a salon as a hairdresser for 20 years, enjoys reading and watching television. Married with one adult child. Denies tobacco use and reports to drinking wine with dinner or weekends to relax. Denies any other drug use. Patient reports wearing a safety belt while driving, denies exercise and described diet as “steak and potatoes.”,   

Fam Hx:  

Mother died three years ago from DM  

Father died in car accidents at age 59 ten years ago  

Grandparents both deceased before the patient was born.   

One brother who is healthy with no known illnesses  

Adult child is obese with borderline diabetes.   

ROS:   

GENERAL: Denies weight loss, fever, chills, fatigue, +weakness in the right hand.  

SKIN: denies rash or itching, denies open sores or wounds.  

CARDIOVASCULAR:  denies chest pain, chest pressure or chest discomfort. denies palpitations, edema.  

RESPIRATORY:  denies shortness of breath, cough or sputum, dyspnea on exertion, night sweats, exposure to TB.  

NEUROLOGICAL:  + reports numbness and tingling to thumb index and middle fingers on the right hand. Denies headache, dizziness, syncope, paralysis, ataxia, No change in bowel or bladder control.  

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.  

O.  

Physical exam:   

Vitals 132/80, 76, 16, 37.6c, 98%  

General: alert and oriented x4, cooperative, does not appear to be in acute distress, good posture while sitting, steady gait when ambulating, good historian.   

Skin: Skin is warm, dry, and intact   

Respiratory: symmetric, no visible abnormal findings, no use of accessory muscles in breathing, breath sounds CTA in all lobes.   

Cardiovascular: Heart rate regular rate and rhythm, S1 and S2 heard, no extra heart sounds heard, distal pulses are 2+ bilaterally, no edema noted, normal hair distribution in legs.   

Musculoskeletal- full ROM in the left upper extremity. Limited range of motion to the right upper extremity. Right weakened thumb abduction, hypalgesia  

Neurological: alert, attentive, and oriented; speech clear & fluent with reasonable comprehension; able to provide a clear account of historical and recent events. Motor- Motor: normal bulk, tone, and strength 5/5 left 4/5 right hand. Sensory: vibration felt in toes and fingers bilaterally; pinprick intact in feet, pinprick intact in hand bilaterally. Superficial pain sensation is not intact in right fingers. Reflexes: 2+ and symmetric at biceps, triceps, knees, and ankles; plantar responses flexor bilaterally. Coordination: normal fine finger movements, finger-nose-finger, and heel-knee-shin.  

Diagnostic results: – X-ray to r/o broken bone or sprain, A1C lab d/t p.t having DM which can damage nerves over time, + Phalen, +Tinel, manual carpal compression, and hand elevation tests  

A.  

Differential Diagnoses   

Carpal tunnel: is caused by compression of the median nerve. Several conditions have been linked to carpal tunnel such as obesity, female ages 40-60 is at higher risk, numbness and tingling of the thumb and radial fingers, clumsiness. a coexisting condition such as diabetes, and workplace factors that are often seen in hairdressers such as repetitive hand and wrist use, working with vibrating tools, prolonged extension, and flexion. (Kothari, 2019)  

Diabetes: Diabetic neuropathy is the result of nerve ischemia due to the direct effects of hyperglycemia on neurons, and intracellular metabolic changes that impair the function of nerves. (Brutsaert, 2019) This patient should be screened for diabetes, which could cause nerve pain, numbness, or decreased ability to feel pain. Tingling or burning, cramps, sensitivity to touch, and weakness. The patient in this case study reports all the signs and symptoms.  

C6 radiculopathy: sudden onset of severe unilateral neck pain. Associated with weakness and numbness predominantly of the dorsal aspect of the first and second fingers and lateral aspect of forearm. (Rainville, et al., 2017)  

Radial nerve compression syndrome: This syndrome affects the radial nerve, which extends the length of the arm. It can impact the wrist, hand, and finger function. It is more common in women between the age of 30-50. According to Moradi, Ebrahimzadeh, and Jupiter (2015), It occurs from intermittent compression on the radial nerve from the radial head to the inferior border of the supinator muscle, without apparent extensor muscle weakness. The authors noted that the exact site of pain and weakness of the third finger and wrist extension are valuable physical exams to diagnosis. (Moradi, Ebrahimzadeh & Jupiter, 2015)  

Anterior Interosseous Nerve Syndrome: is a motor branch from the Median nerve and runs deep in the forearm along with the anterior interosseous artery. It innervates three muscles in the forearm and five muscle in hand, over time can affect the joints of the thumb, and joints at the 2nd and 3rd digits if not diagnosed correctly. According to Aljawder, Faqi, Mohamed, and Alkhalifa (2016) On physical examination, the Pinch Grip test is positive where patients will not be able to demonstrate the “OK” sign, instead of clamping the sheet between an extended thumb and index finger 

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

References 

Aljawder, A., Faqi, M. K., Mohamed, A., & Alkhalifa, F. (2016). Anterior interosseous nerve syndrome diagnosis and intraoperative findings: A case report. International journal of surgery case reports21, 44–47. doi:10.1016/j.ijscr.2016.02.021  

Brutsaert, E. F. (2019). Complications of Diabetes Mellitus – Endocrine and Metabolic Disorders. Retrieved from https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/complications-of-diabetes-mellitus?query=Compression neuropathy  

Kothari, M. J. (2019). Carpal tunnel syndrome: Etiology and epidemiology. Retrieved from https://www.uptodate.com/contents/carpal-tunnel-syndrome-etiology-and-epidemiology?source=autocomplete&index=0~1&search=carp  

Moradi, A., Ebrahimzadeh, M. H., & Jupiter, J. B. (2015). Radial Tunnel Syndrome, Diagnostic and Treatment Dilemma. The archives of bone and joint surgery3(3), 156–162. 

Rainville, J., Joyce, A. A., Laxer, E., Pena, E., Kim, D., Milam, R. A., & Carkner, E. (2017, October 15). Comparison of Symptoms from C6 and C7 Radiculopathy. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28767636