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.
- By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment.
Case Study #2- Last name L-R
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
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 fivepossible 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.
|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.
|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.
|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.
|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.
|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.||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.
|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.
|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.
|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.
|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.
|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.
|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.
|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
|5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
|4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
|3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
|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.||5 (5%) – 5 (5%)
Uses correct APA format with no errors.
|4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors.
|3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors.
|0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors.
|Total Points: 100|
Week 9: Shadow Health Comprehensive SOAP Note Template
Patient Initials: _______ Age: _______ Gender: _______
Chief Complaint (CC):
History of Present Illness (HPI):
Past Medical History (PMH):
Past Surgical History (PSH):
Significant Family History:
Review of Systems:
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
Expert Answer and Explanation
Week 9 Comprehensive Assessment
Patient Initials: ____JT___ Age: ____47___ Gender: ______Female_
Chief Complaint (CC): “Pain in the right wrist”
History of Present Illness (HPI): JT is s a 47-year-old female patient presenting to the facility with a chief complaint of “pain in the right wrist”. The patient notes that the pain has persisted now for two weeks. The pain is located in her right wrist and is characterized by tingling and numbness in the thumb, index, and middle fingers.
The patient also notes that the condition is making her frustrated since it is affecting her routine hair styling activities where she occasionally drops her styling tools.
Medications: No information on current medication use is provided by the patient.
Allergies: The patient denies any food, medicine, or environmental allergies.
Past Medical History (PMH): The patient is having a history of obesity.
Past Surgical History (PSH): No history of past surgeries reported by the patient
Sexual/Reproductive History: The patient reports having a single partner and is sexually active
Personal/Social History: The patient denies use of illicit drugs or alcohol use.
Health Maintenance: The patient appears to be well-groomed. He usually takes fast food since she is usually engaged at her workplace.
Immunization History: No flu shot received.
Significant Family History: The patient’s father passed away aged 64 with a heart attack being the cause of death. Her father also had diabetes, obesity, and hypertension. Her mother also died of a heart attack aged 60 and had hypertension. One of her siblings aged 33 is obese.
Review of Systems:
General: Denies any fever, sudden weight loss or weight gain, fatigue, chills, or recent illness.
HEENT: Denies any head trauma, pain, redness, or itching of the eyes. Denies any pain in the ear. Denies any nasal, mouth, or throat pains.
Respiratory: The patient reports mild shortness of breath but denies chest pain or congestion.
Cardiovascular/Peripheral Vascular: Denies any cardiovascular symptoms
Musculoskeletal: Denies any MS pain other than on her right wrist.
Neurological: Denies having a headache, lightheadedness, dizziness, seizure, or loss of balance.
Psychiatric: Denies any mental or psychological problems
Skin/hair/nails: Denies any changes in hair, skin, or nails
Vital signs: BP 128/82 HR 78 RR 15 SPO2 99% TEMP 37.2 C BMI 34
General: The patient is well-groomed and dressed appropriately for the occasion and weather. The patient is alert and oriented to person, place, time, and situation
The patient is able to clearly answer all questions, with positive eye contact during the entire interview. No distress was noted.
Chest/Lungs: Breath sound and lungs clear to auscultation bilaterally, no cough or adventitious breath sound noted, the chest is even bilaterally. Mildly labored breathing was observed,
Heart/Peripheral Vascular: Regular HR, No murmurs, gallops, bruit, or thrill noted. Carotid equal bilaterally. Capillary refill less than three in fingernails, no edema noted in upper extremities,
Musculoskeletal: Intrinsic muscle of the hand was without atrophy, full pulses, strength 5+/5+. Full ROM in both wrists.
Neurological: Rapid alternating hand movement bilaterally, stereogenesis, and graphesthesia results are within normal limits.
Based on the patient’s condition, there are various diagnostics that should be performed. The first test is to have an x-ray done to a certain whether there are any MS abnormalities. AN X-ray of the affected wrist will help to eliminate any differentials such as fracture and wrist arthritis linked with the wrist pain (Kgoebane et al., 2018). Another important diagnostic is electromyography (EMG).
Conducting an EMG will help to rule out any muscle damage controlled by the median nerve, and will also help narrow down on the differentials (Sonoo et al., 2018). An alternative to an EMG test would be to perform an MRI scan. The third test is the nerve conduction study which the physician may order to determine whether there is any nerve damage.
This is done by measuring how fast an electrical impulse travels through a nerve. A slower electrical response in the carpal tunnel could be indicative of carpal tunnel syndrome (Sonoo et al., 2018).
Carpal tunnel syndrome: From the patient’s symptoms, the most likely diagnosis is carpal tunnel syndrome. According to Sonoo et al. (2018), carpal tunnel syndrome is caused by compression of the median nerve as it travels through the wrist’s carpal tunnel. It is a common entrapment neuropathy associated with over 90% of all neuropathies.
It is a condition that is most prevalent in middle-aged women (Genova et al., 2020). Some of the linked symptoms of the disease include pain associated with tingling and numbness of the wrist, weakness in the hand causing objects to fall. These symptoms are synonymous with what the patient is presenting. There are several risk factors attached to the condition some of which include, high BMI score, sedentary lifestyle, high salt intake, and occupation (Genova et al., 2020).
Therefore, the patient being obese and engaging in repetitive wrist activities are also factors that led to the consideration of carpal tunnel syndrome as a primary diagnosis.
Wrist Arthritis – Another possible diagnosis for wrist pain is wrist arthritis. Wrist arthritis is caused by the loss of cartilage between the wrist bones leading to pain and stiffness. Other symptoms include swelling, weakness on the wrist, difficulty in gripping objects, all of which are observed on the patient (Kang et al., 2018). There are various types of arthritis that can affect the wrist, that is; osteoarthritis, rheumatoid arthritis, and posttraumatic arthritis.
Fractures – Another possible diagnosis is a fracture. Fractures are associated with pain, bruising tenderness, and swelling of the wrist. However, the patient did not recollect any recent or past injuries that could result in a wrist fracture making it not considered as a primary diagnosis.
Flexor carpi radialis tenosynovitis – Another differential is flexor carpi radialis tenosynovitis. This is a condition associated with pain above the volar radial wrist. The condition is caused by inflammation of the FCR tendon sheath (Blood et al., 2016).
Gout – The fifth possible diagnosis is gout. Regarded as another form of arthritis, gout is a condition that is linked with an impaired excretory system, where excess uric acid crystallizes and settles in the joints. The condition is characterized by intense bouts of burning pain and inflammation of the joints, including the wrist (Singh & Gaffo, 2020). The attacks are more common during nighttime.
Blood, T. D., Morrell, N. T., & Weiss, A. P. C. (2016). Tenosynovitis of the hand and wrist: a critical analysis review. JBJS Reviews, 4(3). doi: 10.2106/JBJS.RVW.O.00061
Genova, A., Dix, O., Saefan, A., Thakur, M., & Hassan, A. (2020). Carpal Tunnel Syndrome: A Review of Literature. Cureus, 12(3), e7333. https://doi.org/10.7759/cureus.7333
Kang, G., Leow, M. Q. H., & Tay, S. C. (2018). Wrist inflammation: a retrospective comparison between septic and non-septic arthritis. Journal of Hand Surgery (European Volume), 43(4), 431–437. https://doi.org/10.1177/1753193417738166
Kgoebane, K., Ally, M., Duim-Beytell, M. C., & Suleman, F. E. (2018). The role of imaging in rheumatoid arthritis. SA Journal of Radiology, 22(1), 1316. https://doi.org/10.4102/sajr.v22i1.1316
Singh, J. A., & Gaffo, A. (2020). Gout epidemiology and comorbidities. Seminars in arthritis and rheumatism, 50(3S), S11–S16. https://doi.org/10.1016/j.semarthrit.2020.04.008
Sonoo, M., Menkes, D. L., Bland, J., & Burke, D. (2018). Nerve conduction studies and EMG in carpal tunnel syndrome: Do they add value?. Clinical Neurophysiology Practice, 3, 78–88. https://doi.org/10.1016/j.cnp.2018.02.005
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