Assessing Neurological Symptoms

m​‌‍‍‍‌‍‍‌‍‌‌‍‍‍‌‍‌‌‌‍​agine 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. CASE STUDY 1: Headaches A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw. TO PREPARE: Your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. 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. ***ATLEAST 5 ACADEMIC/SCHOLARLY/SOURCES REQUIRED NOTE: THIS ASSIGNMENT IS LIKE THE OTHER EPISODIC ASSIGNMENT YOU PREVIOUSLY DID, YOU CAN INCLUDE ANY MISSING INFORMATIONS THAT YOU THIK MIGHT BE HELPFUL IN DIAGNOSING THE PATIENT (SUCH AS PAST MEDICAL HISTORY, FAMILY HISTORY, SOCIAL HISTORY, MEDICATIONS, ALLERGIES, ETC.. Learning Resources FOR NURS 6512 Advanced Health Assessment and Diagnostic Reasoning 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” 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 ch​‌‍‍‍‌‍‍‌‍‌‌‍‍‍‌‍‌‌‌‍​apter 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”)

 

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