Assignment 1: Case Study Assignment: Assessing Neurological Symptoms NURS 6512N-32
Case 1: Headache
Patient Information:
Initials: P.K Age: 20 years old Sex: Male Race: Asian
S.
CC (chief complaint): “Headache”
HPI: P.K is a 20 years old Asian male patient who presented to the clinic complaining of intermittent headaches. He claims that the headache diffuses all over the head. However, the patient claims that the pressure and intensity are mainly located on the forehead above the eyes, the jaw, cheekbones, and the nose.
Location: head
Onset: The patient claims that the headache started 3 days before the present visit.
Character: He describes the pain as dull and pounding.
Associated signs and symptoms: photophobia, phonophobia, and nausea
Timing: Intermittent
Exacerbating/ relieving factors: Placing a cool rag on the forehead alleviates the pain, while it is worsened by noise.
Severity: 7/10 on a pain scale
Current Medications: Flonase nasal spray, which he administers 2 sprays per nostril only once a day to manage the symptoms resulting from seasonal allergies. Over-the-counter Tylenol 1g orally after every six hours, PRN for management of the headache.
Allergies: None.
PMHx: Underwent appendectomy at an early age, when he was 10 years old. In 2008, the patient underwent spinal fusion surgery L4-L5, and cervical spinal fusion T2-T3 in 2010, as a result of degenerative disk disease.
Vaccination: Last tetanus vaccine in 2010. The patient’s last flu shot was administered in October 2020. Confirms that all the childhood development immunization is up to date.
Soc Hx: The patient is an accountant and takes part in competitive throwing of darts. He is currently single, and heterosexual but with no sexual partner at the moment. He denies having any plan to date soon. He denies smoking or being a passive smoker. He does not take alcohol. Safety characters are exhibited as he uses a seat belt when driving and reports that there are no guns at his place. He confirms taking coffee up to 3 cups a day. In addition to soda and caffeinated beverages.
Fam Hx: Father is still alive at the age of 81 years, managing skin cancer, HTN, and coronary artery disease. Mother passed on at the age of 71 years from breast cancer. All the grandparents passed on with no known health complications. The patent has only one sibling who is struggling with CVA at the age of 55.
ROS:
GENERAL: No recent changes in body weight, appetite, fever, chills, fatigue, nausea, or vomiting.
HEENT: Head: No signs of trauma, with equal hair distribution. Eyes: No changes in visual acuity, yellow sclera, or a history of using visual aid. Confirms increased eye sensitivity to light when experiencing headaches. Ears: No discharge, pain, tinnitus, hearing problems, or itchiness. Nose: Reports painful sinuses during headaches, and seasonal rhinitis. Throat: No sore throat, difficulties in swallowing, or enlarged thyroid.
SKIN: Smooth and warm, with no signs of infections or pruritus.
CARDIOVASCULAR: Denies chest problems, pressure, pain, or heart racing.
RESPIRATORY: Denies congestions, coughing, dyspnea, or wheezing
GASTROINTESTINAL: No signs of abdominal distension, pain on palpation, or mass.
GENITOURINARY: No changes in urine frequency, polyuria, or burning sensation when urinating.
NEUROLOGICAL: Reports intermittent headaches. No signs of seizures, dizziness, or changes in bladder or bowel movement.
MUSCULOSKELETAL: Denies stiffness of joints or muscle fatigue and pain.
HEMATOLOGIC: No history of blood disorders.
LYMPHATICS: Denies enlargement of lymph nodes.
PSYCHIATRIC: Denies any current psychiatric symptoms. Reports a history of anxiety and depression which is resolved.
ENDOCRINOLOGIC: Denies heat or cold intolerance, polydipsia, or polyuria.
ALLERGIES: Reports latex and seasonal allergies. Denies any other allergic condition.
O.
Physical exam:
Vitals: BP 110/85; P 76; T 98.6; R 17 PsaO2 98% room air.
GENERAL: Appears well-nourished with age-appropriate clothing. Reports intermittent headache, photophobia, phonophobia, sound intolerance, and occasional nausea and vomiting as a result of the headache.
HEENT: Head: Atraumatic with equal distribution of hair. Eyes: No signs of inflammation, redness, or itchiness. Clear sclera. Equal pupil reaction to light bilaterally. Ears: PEARL tympanic membrane. No signs of erythema. Nose: patent naris, intact septum, and mild clear rhinorrhea seen. No signs of ulceration or inflammation of the gums. Throat: No signs of swollen tonsils.
NECK: Symmetric with the aligned trachea. Palpable thyroid gland with no signs of abnormalities.
CARDIOVASCULAR: S1 and S2 noted. No irregular or abnormal sounds. Regular heart rate and rhythm.
RESPIRATORY: Clear lung sounds. No rales or abnormal sounds were noted.
NEUROLOGICAL: Responds appropriately to questions. Well oriented in person, place, and time. bilaterally equal pupil with a similar light response. Displays equal handgrip strength. Long-term and short-term memories are intact (Balgetir et al., 2019). On a pain scale from 0 to 10 with 0 being mild and 10 severe, the patient rates the pain 7/10. The headache is also associated with photophobia, nausea, and vomiting.
Diagnostic results: Routine lab tests such as CBC and white blood cell count ordered to check for signs of infection. Sinus Aspiration was performed to confirm bacterial sinusitis. Nasal smear and nasal scarping do evaluate the presence of allergic rhinitis. An allergic skin test was also performed to assess the reasons behind the seasonal allergy (Itanyi et al., 2020). Nasal endoscopy, CT scan, and MRI to assess the severity of the patient’s condition, by observing the brain tissue anatomy and the soft tissue pathology.
A.
Differential Diagnoses
Acute Sinusitis: This is a short-term inflammatory condition of the sinuses lasting for less than 4 weeks. It is most common among individuals with seasonal allergies. Patients diagnosed with this disorder normally present with facial pain, tenderness and pressure, stuffy nose, thick yellow-greenish discharge, nasal congestion, headache, fever, and ear pain (Kirsch, 2019). The patient in the provided case scenario presented most of these symptoms with the chief complaint of sinus headache, presenting as pressure around the forehead, cheeks, and eyes. This disorder meets the patient’s diagnostic threshold from the provided history and examination results.
Migraine without aura: This disorder is characterized by paroxysmal pain episodes which last for about 4 to 72 hours and are associated with symptoms such as photophobia, phonophobia, nausea, and vomiting (Diener et al., 2020). The patient in the provided case study displayed all the above four symptoms. This disorder is also diagnosed when the cause of the patient’s headaches is not associated with another disorder. The patient, however, displays several symptoms which show that the pain might be a result of other causes.
Medication rebound headache: medication overuse headache or rebound headaches normally result from long-term use of pain medication for conditions such as migraines. Common signs and symptoms include nausea, memory loss, irritability, restlessness, and intermittent headaches (Chinthapalli et al., 2018). The patient in the provided case study complains of intermittent headache and nausea. Consequently, he has been on pain medications for an extended period, as a result of the three surgeries which he went through.
Allergic Rhinitis: Commonly referred to as hey fever is an immune disorder caused by seasonal or perennial allergies. The disease is characterized by sneezing, running nose, sneezing, fatigue, itchy eyes, and frequent headaches (Ceriani, & Silberstein, 2021). The patient in the provided case study has seasonal allergies with a history of allergic rhinitis. He also presents with intermittent headache which makes allergic rhinitis a differential diagnosis.
Rhinitis medicamentosa: This is a non-allergic type of rhinitis which results from prolonged use of nasal decongestants topically. In this case, prolonged use means more than 5 straight days (Smith et al., 2019). Patients will present with sneezing, postnasal drip, or nasal congestion without rhinorrhea. Some patients might display intermittent headaches with compliance to pressure just like the patient in the provided case study.
Assignment 1: 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.
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
Assignment 1 Case Study Assignment Assessing Neurological Symptoms NURS 6512N-32.PNG
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.
Learning Resources
Required Readings (click to expand/reduce)
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”
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”
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”
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”
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”
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)
Note: Download the Physical Examination Objective Data Checklist to use
as you complete the Comprehensive (Head-to-Toe) Physical Assessment
assignment.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2011). Physical examination objective data checklist. In
Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier
Mosby.
Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A.,
Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance
Center.
Note: Download and review the Student Checklists and Key Points to use
during your practice neurological examination.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Neurologic system: Student checklist. In Seidel’s guide to physical
examination: An interprofessional approach (9th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Neurologic system: Key points. In Seidel’s guide to physical
examination: An interprofessional approach (9th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Mental status: Student checklist. In Seidel’s guide to physical
examination: An interprofessional approach (9th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
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.
Athilingam, P ., Visovsky, C., & Elliott, A. F. (2015). Cognitive screening in
persons with chronic diseases in primary care: Challenges and
recommendations for practice. American Journal of Alzheimer’s Disease &
Other Dementias, 30(6), 547–558. doi:10.1177/1533317515577127
Sinclair , A. J., Gadsby, R., Hillson, R., Forbes, A., & Bayer, A. J. (2013).
Brief report: Use of the Mini-Cog as a screening tool for cognitive
impairment in diabetes in primary care. Diabetes Research and Clinical
Practice, 100(1), e23–e25. doi:10.1016/j.diabres.2013.01.001
Roalf, D. R., Moberg, P. J., Xei, S. X., Wolk, D. A., Moelter, S. T., &
Arnold, S. E. (2013). Comparative accuracies of two common screening
instruments for classification of Alzheimer’s disease, mild cognitive
impairment, and healthy aging. Alzheimer’s & Dementia, 9(5), 529–537.
doi:10.1016/j.jalz.2012.10.001. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036230/
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation
as well as other support resources:
Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file].
Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY
Shadow Health. (n.d.). Shadow Health help desk. Retrieved
from https://support.shadowhealth.com/hc/en-us
Document: Shadow Health. (2014). Useful tips and tricks (Version 2)
(PDF)
Document: Student Acknowledgement Form (Word document)
Note: You will sign and date this form each time you complete your DCE
Assignment in Shadow Health to acknowledge your commitment to
Walden University’s Code of Conduct.
Document: 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.
Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s
diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
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.
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.
Required Media (click to expand/reduce)
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/
Name: NURS_6512_Week_9_Assignment1_Rubric
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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.
Points Range: 45 (45%) – 50 (50%)
The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
Points Range: 39 (39%) – 44 (44%)
The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
Points Range: 33 (33%) – 38 (38%)
The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected.
Points Range: 0 (0%) – 32 (32%)
The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
· List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Points Range: 30 (30%) – 35 (35%)
The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study and provides a thorough, accurate, and detailed justification for each of the five conditions selected.
Points Range: 24 (24%) – 29 (29%)
The response lists four to five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected.
Points Range: 18 (18%) – 23 (23%)
The response lists three to four possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or some inaccuracy in the conditions and/or justification for each.
Points Range: 0 (0%) – 17 (17%)
The response lists three or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
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.
Points Range: 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
Points Range: 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
Points Range: 3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.
Points Range: 0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation
Points Range: 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
Points Range: 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
Points Range: 3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
Points Range: 0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
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.
Points Range: 5 (5%) – 5 (5%)
Uses correct APA format with no errors.
Points Range: 4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors.
Points Range: 3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors.
Points Range: 0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors.
Total Points: 100
Name: NURS_6512_Week_9_Assignment1_Rubric
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