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

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.

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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). . 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). . 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). . 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 from

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.

Week 9 NEURO SOAP Note

 

Patient Initials: T.N              Age: 67 years                        Gender: Male

 

 

SUBJECTIVE DATA:

 

Chief Complaint (CC): “Very Forgetful”

 

History of Present Illness (HPI): N.S is a 67-year-old Asian male who was brought in by his daughter for psychiatric evaluation since he was very forgetful. She reports that the patient has lost his car keys several times. She also reports that sometimes when the patient goes to the store, he forgets his way back and calls for help. The patient claims that he started being forgetful about 2 years back, and it has been getting worse ever since as reported by his daughter. The patient denies any associated symptoms. No hallucination or delirium.

 

Medications:

  1. Losartan 50mg PO once daily for the management of his high blood pressure.

 

Allergies:

No known drug, food, or environmental allergies

 

Past Medical History (PMH):

High Blood Pressure

 

Past Surgical History (PSH):

Denies ever undergoing any surgical procedure in the past.

 

Sexual/Reproductive History:

Heterosexual

 

Personal/Social History:

Married with a daughter and a son. His wife however passed on 2 years ago.

Retired but owned and ran his café downtown for several years.

He lives by himself, but the daughter lives next door and checks on him now and then.

Confirms taking one or two beers when with friends.

Denies smoking tobacco or using any other recreational drug.

 

Health Maintenance:

The patient used to exercise before by walking the dog, but ever since he started being forgetful, he does not remember the last time he went for a long walk. He however consumes a healthy diet which his daughter makes sure of. He uses a seat belt when in the care and lives in a well-maintained house. Confirms sleeping for about 8 hours every night.

 

Immunization History:

Flu shot 16/1/2022

Covid Vaccine #1 4/1/2021 #2 2/1/2021 Moderna

All other immunization up to date

Significant Family History:

The patient’s mother passed on at the age of 86 years due to cardiac arrest, upon receiving a report that her grandson had been involved in a car accident. His father is alive at the age of 94 years with a history of diabetes, dementia, arthritis, and thyroid disorder. Both his children are healthy with no significant history of any chronic medical condition.

 

Review of Systems:

General: Appears healthy with no signs of distress. No signs of fatigue, chills, fever, or generalized body weakness.

 

HEENT: Head: No signs of trauma or headache reported. Eyes: Denies blurred vision, use of corrective lenses, excessive tearing, or redness. Ears: No tinnitus, itchiness, or hearing loss. Nose: no congestion, running nose, sinus problems, or nose bleeding. Throat & Mouth: No sore throat, coughing, swallowing difficulties, or dental problems. Neck: No tenderness, signs of injury, enlarged tonsils, or a history of disc disease or compression.

 

Respiratory: No wheezing, coughing, shortness of breath, or breathing difficulties.

 

CV: Denies chest pain, edema, orthopnea, syncope, or palpitations. Dyspnea on exertion

 

GI: No abdominal tenderness, constipation, diarrhea, distention, changes in bowel movement, or jaundice.

 

GU: Denies incontinence, urinary frequency, hematuria, dysuria, or burning sensation when urinating.

 

MS: Denies back pain, with a full range of movement in all the extremities. No signs of spinal code injury.

 

Psych: Denies paranoia, hallucinations, delirium, suicidal ideation, mental disturbance, memory loss, anxiety or depression, or a history of psychosis.

 

Neuro: Denies vertigo, tremors, syncope, seizures, paresthesia, or transient paralysis.

 

Integument/Heme/Lymph: No bruising, ecchymosed, ulcers, lesions, or rashes. No signs of enlarged lymph nodes.

 

Endocrine: Denies heat intolerance, cold intolerance, polyuria, polyphagia, or polydipsia.

 

Allergic/Immunologic: Denies hay fever, urticaria, or persistent infections.

 

OBJECTIVE DATA:

 

Physical Exam:

 

Vital signs: T: 97.7°F (36.5°C), BP: 125/70 mm Hg, HR 70/min, R: 18/min, memory loss 8/10. Ht. 5’9’’, Wt. 179 pounds, BMI: 23.5

 

General: N.S appears healthy and well cooperative through the examination with a pleasant mood. He experiences no chills, fever, fatigue, or recent changes in body weight.

 

Chest/Lungs: Lungs are clear to auscultation and percussion bilaterally. No rhonchi or wheezing.

 

Heart/Peripheral Vascular: S1 and S2 present. No rubs, gallops, or murmurs. Regular rate and rhythm

 

Lymphatics: No signs of enlarged lymph nodes.

                       

Neurological: The CN II-VII and the DTR are undamaged. Denies headache, syncope, or dizziness. Confirms worsening memory loss for the past 2 years

 

Psychiatric: Denies feeling hopeless, or having suicidal ideations. Confirms being in mild distress due to memory loss leading to cognitive impairment.

 

Diagnostic results:

TSH – To determine if the patient memory loss is associated with hypothyroidism.

MRI of the head – To assess whether there is any form of damage to the neurotransmitters or the presence of any form of brain cell tumor.

Cerebral angiography – To measure the blood flow through the brain for any signs of deficiencies.

Amyloid imaging –

Cognitive test – To determine whether the patient’s memory loss is associated with anxiety or distress (Bruno, 2020).

 

ASSESSMENT:

 

  1. Alzheimer’s disease: Alzheimer’s disease is a progressive neurologic disorder that leads to atrophy of the brain and death of brain cells (Glymour et al., 2018). This disorder is the most common form of dementia among the elderly above the age of 65 years. It is characterized by significant cognitive deterioration which undermines the patient’s ability to sustain independent living. The diagnosis of this disorder is based on three stages, with the first stage regarded as the preclinical stage with no symptoms. The second stage which is referred to as the middle stage is characterized by mild cognitive impairment, whereas the final stage is characterized by marked symptoms of dementia. The patient in the provided case study presents with worsening memory loss, for the past two years, which indicates the final stage of Alzheimer’s as the primary diagnosis.
  2. Vascular cognitive impairment (VCI): This is a disorder of the mind with undermines the patient’s mental ability to think, feel and be awake (Ghafar et al., 2019). VCI presents with cognitive symptoms ranging from being forgetful in mild cases. However, in severe cases, patients may present with serious cognitive impairments leading to problems with memory, attention, language, and executive functions such as problem-solving. The patient in the provided case study reports being forgetful, However, cognitive testing is required to confirm this diagnosis.
  3. Vascular dementia: This refers to a decline in the patients thinking skills due to conditions that reduce or block the flow of blood to various parts of the brain, depriving them of nutrients and oxygen (Bruno, 2020). Patients will present with symptoms such as forgetfulness, poor balance, confusion, and disorientation among others. The patient in the provided case study however presented with forgetfulness only, with no associated symptoms.
  4. Idiopathic normal pressure hydrocephalus (INPH): This is a disorder of the brain characterized by impairment of the patient’s gait, urinary incontinence, and decline in cognitive function. It is normally associated with ventriculomegaly in the absence of increased cerebrospinal fluid (CSF) pressure (Kockum et al., 2020). Forgetfulness and confusion are one of the most common early symptoms, among others such as depression, trouble walking, poor balance, and falling. Neuroimaging with either CT or MRI is however required to confirm this diagnosis to assess for hydrocephalus pressure.
  5. Lewy body dementia (LBD): It is a rare disease associated with abnormal deposition of alpha-synuclein in the brain. These deposits, known as Lewy bodies lead to a progressive decline in the patient’s cognitive ability (Gan et al., 2021). Patients will present with common signs and symptoms such as memory loss, tremors, slow movement, muscle rigidity, loss of coordination, and reduced facial expression. However, the diagnosis of this disorder requires the patient to present with declining thinking ability in addition to at least two of the following symptoms, parkinsonian symptoms, repeated visual hallucinations, and fluctuating alertness.

 

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


 

References

Bruno, A. (2020). Forgetfulness. The Family Nurse Practitioner: Clinical Case Studies, 245-249.

Gan, J., Liu, S., Wang, X., Shi, Z., Shen, L., Li, X., … & Ji, Y. (2021). Clinical characteristics of Lewy body dementia in Chinese memory clinics. BMC neurology21(1), 1-11. https://doi.org/10.1186/s12883-021-02169-w

Ghafar, M. Z. A. A., Miptah, H. N., & O’Caoimh, R. (2019). Cognitive screening instruments to identify vascular cognitive impairment: A systematic review. International Journal of Geriatric Psychiatry34(8), 1114-1127.

Glymour, M. M., Brickman, A. M., Kivimaki, M., Mayeda, E. R., Chêne, G., Dufouil, C., & Manly, J. J. (2018). Will biomarker-based diagnosis of Alzheimer’s disease maximize scientific progress? Evaluating proposed diagnostic criteria. European Journal of Epidemiology33(7), 607-612. https://doi.org/10.1007/s10654-018-0418-4

Kockum, K., Virhammar, J., Riklund, K., Söderström, L., Larsson, E. M., & Laurell, K. (2020). Diagnostic accuracy of the iNPH Radscale in idiopathic normal pressure hydrocephalus. PLoS One15(4), e0232275.

 

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