NURS 6512 Case Study: Assessing Neurological Symptoms Assignment Paper
NURS 6512 Case Study: Assessing Neurological Symptoms Assignment Paper
NURS 6512 Case Study: Assessing Neurological Symptoms Assignment Paper Sample
Assignment 1: Case Study Assignment: Assessing Neurological Symptoms
Episodic/Focused SOAP Note Template
Patient Information:
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Initials: H.F. Age: 47 Years Sex: Female Race: Caucasian
S.
CC (chief complaint): “I am experiencing pain in my right wrist”
HPI: H.F., a 47-year-old Caucasian female with obesity, sought medical attention at the clinic due to her primary concern of experiencing pain in her right wrist, accompanied by sensations of numbness and tingling in the index, middle finger, and thumb. The patient has provided an account of experiencing these symptoms approximately fourteen days prior. Nevertheless, she expresses apprehension regarding the discomfort, as it causes her to inadvertently release her hairstyling implements.
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Location: Right wrist
Onset: two weeks ago
Character: Numbness and pain in her right wrist
Associated signs and symptoms: Thumb, middle, and index finger tingling
Timing: the whole day
Exacerbating/ relieving factors: Worse while doing tasks with the wrist joint. When the wrist is stationary, the discomfort is reduced.
Severity: 6/10
Current Medications:
- Ibuprofen at a dosage of 400mg taken orally as needed,
- Hydrochlorothiazide at a dosage of 25mg taken orally every morning
- Amlodipine at a dosage of 10mg taken orally once daily.
Allergies: Allergic to sulfur. No environmental or food allergies.
PMHx: The patient exhibits obesity and has a documented history of hypertension.
- Immunization status: The patient has received all necessary vaccinations, including Tdap in October 2020, the Influenza Vaccine during the current season, and completed the COVID-19 Vaccines with Boosters in 2021.
- Surgeries: without any prior surgical history
- Hospitalization: There is no record of any hospitalizations.
Soc Hx: The patient is a hairdresser who works five blocks from her house in a neighborhood spa. She claims to have a history of sometimes consuming alcohol while smoking cigarettes. She does not, however, admit to using marijuana or any other illegal substance. She presently lives as a family with her husband and three kids. During her free time, she enjoys singing and reading. She exercises by taking the dog for a 30-minute walk every evening. She affirms that she eats a healthy diet and sleeps well for around 8 hours each night.
Fam Hx: The patient has two siblings, the younger of whom has just received an asthma diagnosis while the other is well. Both of her parents are still living; the mother has a history of T2DM and HTN, while the father has a history of HTN and esophagostomy. She is unaware of the medical history of her grandparents.
ROS:
GENERAL: denies any symptoms of heat or cold sensitivity, reduced appetite, sluggishness, chills, fever, or recent weight changes.
HEENT: Head: denies experiencing seizures, headaches, or dizziness. Eye: denies any discomfort, discharge, vision disturbances, photophobia, or blurriness. Ear: denies discharge, tinnitus, discomfort, or hearing loss. Nose: denies having sneeze fits, sinus pain, a runny nose, or nose bleeding. Throat: denies pain, swallowing issues, or voice hoarseness.
SKIN: denies rash or itching.
CARDIOVASCULAR: denies having orthopnea, arrhythmias, elevated blood pressure, or palpitations.
RESPIRATORY: denies having a cough, producing phlegm, having breathing problems, or breathing quickly.
GASTROINTESTINAL: denies experiencing vomiting, heartburn, heartburn pain, discomfort, or abdominal distention.
GENITOURINARY: denies having hematuria, vaginal discharge, incontinence, dysuria, oliguria, frequent urination, or burning pain.
NEUROLOGICAL: denies experiencing ataxia, a headache, paralysis, syncope, or abnormalities in bowel or bladder control. reports tingling and numbness in the middle, index, and thumb fingers.
MUSCULOSKELETAL: a right wrist ache is reported. denies muscular pain, joint stiffness, or joint swelling. demonstrates the complete range of motion in other joints.
HEMATOLOGIC: denies bleeding issues, easy bruising, or anemia.
LYMPHATICS: denies splenectomy or lymphadenopathy.
PSYCHIATRIC: denies experiencing hallucinations or other psychological symptoms such as anxiety, sadness, or thoughts of homicide or suicide.
ENDOCRINOLOGIC: denies a tendency to sweat excessively, polyuria, polydipsia, or sensitivity to heat and cold.
ALLERGIES: Sulfur allergy is reported.
O.
Physical exam: Vital signs: BP- 138/86 mmHg, PR-86, RR-19, Temp- 98.9, SpO2-98% on room air, Ht- 5’9”, Wt- 210 lbs., BMI-31.01
GENERAL: a female who is obese and adequately attired. Clear speaking, the patient is focused and aware X4. The patient responds to inquiries adequately and is not visibly distressed.
HEENT: Head: normal-sized, trauma-free, and without scars. Eye: Sclera and conjunctiva are clear. No significant redness, discharge, or tearing. Ear: Typical pinna with an unobstructed tympanic membrane. It is normal for the external auditory canal. Nose: nasal mucous membrane that is wet. No sinuses or discomfort to the touch. Throat: pink, wet mucous membrane in the mouth. The tonsils and posterior pharynx are not erythematous, and the uvula is in the middle.
MUSCULOSKELETAL: Gait and musculoskeletal development are normal. displays a healthy body posture without any joint or bone swelling or abnormalities. Right thumb abduction shows weakness, with a 3/5 poor strength. Positive Hoffmann-Tinel and Phalen indicators. All the muscles of the other limb are strong and their tendon reflexes are normal.
NEUROLOGICAL: Aware and well-grounded in time, location, and people. quite helpful throughout the assessment. All of the cranial nerves are mostly unharmed. demonstrates typical reactions. The right hand’s middle finger, thumb, and index finger all feel numb and tingly.
Diagnostic results: The complete blood count (CBC) reveals a white blood cell count (WBC) of 8.9. Additionally, a comprehensive metabolic panel (CMP) including differentials is performed. The glucose level is measured at 125, while the HgbA1c level is recorded as 4.5%, indicating the need to exclude any potential presence or occurrence. Neuropathy associated with type 2 diabetes mellitus (T2DM). The concentration of C-reactive protein in the sample is 4.2 mg/L (Attal & Didier Bouhassira, 2023).
Diagnostic Tests:
- An X-ray examination of the right wrist was conducted to assess the presence of arthritic changes (Genova et al., 2020).
- Test for bone density to rule out osteoporosis.
- nerve conduction analysis.
- Manual: Tinel sign and Durkans Test (Zhang et al., 2020).
A.
Differential Diagnoses:
- Carpal tunnel syndrome (CTS): This condition is characterized by symptoms such as tingling and numbness in the fingers, which occur due to compression of the median nerve within the carpal tunnel (Malakootian et al., 2022). This condition is commonly regarded as an occupational disease characterized by repetitive wrist and finger extension and flexion. However, certain cases of CTS may have an unknown cause, and the risk of developing CTS can be influenced by various factors, including genetic and acquired factors. A nerve conduction study is a precise diagnostic tool used to identify both normal and abnormal values of nerve function. Diagnostic laboratory results can also be utilized for the identification of increased levels of inflammatory markers. The patient exhibits multiple risk factors for developing this disease, including occupational factors and obesity.
- Peripheral neuropathy: This condition is linked to hand numbness. The patient’s gender, familial history, and weight contribute to their increased risk of developing type 2 diabetes mellitus (T2DM) (Selvarajah et al., 2019). Peripheral neuropathy is a frequently observed symptom associated with T2DM, characterized by a gradual onset. A two-point discrimination test was conducted, revealing decreased sensitivity in the patient’s right arm. The patient reports no decrease in sensation in the lower extremities. If the patient experiences altered symptoms and exhibits new-onset neuropathy in the lower extremities, I will contemplate reevaluating the A1C levels and potentially diagnose diabetic peripheral neuropathy based on diagnostic assessments. Diabetic individuals exhibit significant declines in hand and finger dexterity relative to their healthy counterparts.
- Wartenberg’s syndrome: This condition presents as paresthesia or pain occurring along the radial aspect of the forearm, with symptoms radiating toward the thumb and middle fingers. The pain arises due to the compression of the superficial radial nerve. Potential external factors may include the presence of a wristwatch or objects exerting pressure on the nerve (Kuschner & Berihun, 2021). The technique of palpation in the vicinity of the radial nerve region is employed to detect potential masses located both superficially and deeply. The utilization of the Tinel’s sign aids in the confirmation of this particular diagnosis.
- Lupus: This is an autoimmune disease characterized by immune system dysfunction, resulting in inflammation, a high body temperature, joint pain, malaise, and rash. DNA methylation is a specific and reliable biomarker for the diagnosis of lupus, exhibiting cell-type specificity (Fanouriakis et al., 2020). DNA methylation is more prominent in patients with active disease compared to those in remission. The lupus band test (LBT) is a direct immunofluorescent approach conducted through skin biopsy. It is particularly valuable in cases where clinical and laboratory data are inconclusive for diagnosing lupus.
- Type 2 Diabetes Mellitus (T2DM): The patient is at a heightened risk of developing T2DM. In the event of a gradual increase in the patient’s HbA1c, it is recommended to implement a prediabetes protocol involving lifestyle modifications such as dietary changes, exercise, and regular monitoring of HbA1c levels. Diabetic peripheral neuropathy (DNP) is characterized by progressive metabolic and inflammatory alterations that result in impaired daily functioning and reduced independence (Wu et al., 2021). Fasting lipid levels should be included in laboratory tests to assess cholesterol levels and provide education on cholesterol, triglycerides, LDL, and HDL levels.
References
Attal, N., & Didier Bouhassira. (2023). Neuropathic Pain. https://doi.org/10.1093/med/9780197616345.001.0001
Fanouriakis, A., Tziolos, N., Bertsias, G., & Boumpas, D. T. (2020). Update Οn the Diagnosis and Management of Systemic Lupus Erythematosus. Annals of the Rheumatic Diseases, 80(1), annrheumdis-2020-218272. https://doi.org/10.1136/annrheumdis-2020-218272
Genova, A., Dix, O., Saefan, A., Thakur, M., & Hassan, A. (2020). Carpal Tunnel Syndrome: A Review of Literature. Cureus, 12(3). https://doi.org/10.7759/cureus.7333
Kuschner, S. H., & Berihun, H. (2021). Robert Wartenberg Syndrome and Sign: A Review Article. The Open Orthopaedics Journal, 15(1), 13–16. https://doi.org/10.2174/1874325002115010013
Malakootian, M., Soveizi, M., Gholipour, A., & Oveisee, M. (2022). Pathophysiology, Diagnosis, Treatment, and Genetics of Carpal Tunnel Syndrome: A Review. Cellular and Molecular Neurobiology. https://doi.org/10.1007/s10571-022-01297-2
Selvarajah, D., Kar, D., Khunti, K., Davies, M. J., Scott, A. R., Walker, J., & Tesfaye, S. (2019). Diabetic peripheral neuropathy: advances in diagnosis and strategies for screening and early intervention. The Lancet Diabetes & Endocrinology, 7(12), 938–948. https://doi.org/10.1016/s2213-8587(19)30081-6
Wu, B., Niu, Z., & Hu, F. (2021). Study on Risk Factors of Peripheral Neuropathy in Type 2 Diabetes Mellitus and Establishment of Prediction Model. Diabetes & Metabolism Journal, 45(4), 526–538. https://doi.org/10.4093/dmj.2020.0100
Zhang, D., Chruscielski, C., Blazar, P., & Earp, B. (2020). Accuracy of Provocative Tests for Carpal Tunnel Syndrome. Journal of Hand Surgery Global Online, 2(3), 121–125. https://doi.org/10.1016/j.jhsg.2020.03.002
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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.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
Learning Resources
Required Readings
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 7, “Mental Status”
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.
Chapter 23, “Neurologic System”
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. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 4, “Affective Changes”
Download Chapter 4, “Affective Changes”
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.
Chapter 9, “Confusion in Older Adults”
Download Chapter 9, “Confusion in Older Adults”
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.
Chapter 13, “Dizziness”
Download Chapter 13, “Dizziness”
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.
Chapter 19, “Headache”
Download Chapter 19, “Headache”
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.
Chapter 31, “Sleep Problems”
Download Chapter 31, “Sleep Problems”
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. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5)
O’Caoimh, R., & Molloy, D. W. (2019). Comparing the diagnostic accuracy of two cognitive screening instruments in different dementia subtypes and clinical depression.
Links to an external site. Diagnostics, 9(3), 93. https://doi.org/10.3390/diagnostics9030093
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:
Shadow Health. (2021). Welcome to your introduction to Shadow Health.
Links to an external site. https://link.shadowhealth.com/Student-Orientation-Video
Shadow Health. (n.d.). Shadow Health help desk.
Links to an external site.Retrieved from https://support.shadowhealth.com/hc/en-us
Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students.
Download Walden University quick start guide: NURS 6512 NP students. https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide
Document: DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment (Word document)
Download DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment (Word document)
Use this template to complete your Assignment 3 for this week.
Required Media
Neurologic System – Week 9 (16m)
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 7 and 23 that relate to the assessment of cognition and the neurologic system. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/
Links to an external site.
Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.
Chapter 14, “The Neurologic Examination”
This chapter provides an overview of the nervous system. The authors also explain the basics of neurological exams.
Chapter 15, “Mental Status, Psychiatric, and Social Evaluations”
In this chapter, the authors provide a list of common psychiatric syndromes. The authors also explain the mental, psychiatric, and social evaluation process.
Kim, H., Lee, S., Ku, B. D., Ham, S. G., & Park, W. (2019). Associated factors for cognitive impairment in the rural highly elderly.
Links to an external site. Brain and Behavior, 9(5), e01203. https://doi.org/10.1002/brb3.1203
Lee, K., Puga, F., Pickering, C. E., Masoud, S. S., & White, C. L. (2019). Transitioning into the caregiver role following a diagnosis of Alzheimer’s disease or related dementia: A scoping review.
Links to an external site. International Journal of Nursing Studies, 96, 119–131. https://doi.org/10.1016/j.ijnurstu.2019.02.007
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.
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.
By Day 6 of Week 9
Submit your Assignment.
submission information
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
To submit your completed assignment, save your Assignment as WK9Assgn1+last name+first initial.
Then, click on Start Assignment near the top of the page.
Next, click on Upload File and select Submit Assignment for review.
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Rubric
NURS_6512_Week_9_Assignment1_Rubric
| Criteria | Ratings | Pts | ||||
|---|---|---|---|---|---|---|
| This criterion is linked to a Learning Outcome Using the Episodic/Focused SOAP Template: · Create documentation or an episodic/focused note in SOAP format 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 your case. |
|
50 pts | ||||
| This criterion is linked to a Learning Outcome · List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. |
|
35 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. |
|
5 pts | ||||
| Total Points: 100 | ||||||
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