CASE STUDY ASSIGNMENT 1: ASSESSING NEUROLOGICAL SYMPTOMS

CASE STUDY ASSIGNMENT 1: ASSESSING NEUROLOGICAL SYMPTOMS

CASE STUDY ASSIGNMENT 1: ASSESSING NEUROLOGICAL SYMPTOMS

Assignment 1: Case Study Assignment: Assessing Neurological Symptoms

These cases are for the NEUROLOGICAL SYSTEM. Keep this in mind when writing your SOAP note.

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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Case Study 1: Headaches

A 40 year old female presents with complaint of a headache for one week. Reports a “head cold” 3 weeks ago. Thought it was getting better, but sinus symptoms are back and even worse.

Describes the headache is located across her forehead; feels like pressure behind my eyes and unable to breathe out of nose. Also feels mucus running down the back of throat. Pain sometimes severe (8/10) but with acetaminophen reduces to moderate (4/10) and occasionally mild (2/10). Occasional nonproductive cough. Feels feverish at times; noted frequent sneezing and no appetite. Bending over seems to make the headache worse. “Acetaminophen improves my headache, but doesn’t take it away.” Taking Sudafed HCL 120 mg every 12 hours, with some relief. Symptoms are worse in the morning – awakes with a headache. Ranges from 2/10 at its best to 8/10. Difficulty with concentrating at job and feels very tired.

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.

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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.

PLEASE use the Template in the Resource LIST!

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned.

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.

You are to make up the necessary information to Document a SOAP note focused on the Neurological System.

You DO NOT have to Review (ROS) and Examine (Physical Exam) ALL Systems, only the Systems Relevant to the Chief Complaint.