(Solution) NURS 6512 Assignment 1: Case Study Assignment: Assessing Neurological Symptoms

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.

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 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.

Solution:

Case 1: Headaches

Patient Information: A 20-year-old man

SUBJECTIVE DATA:

Chief Complain: Intermittent headaches

HPI: Patient experiences an intermittent headache that tends to diffuse all over the head. The pain is more intense around the jaw, cheekbone, nose, and above the eyes.

Medications: No records of past medical use

Allergies: No allergy to drug, food, or environment known

Past Medical History (PMH): Not available

Past Surgical History (PSH): Not provided

Social History: No social history available

Immunization History: Not provided

Significant Family History: Not Known

Lifestyle: Not known

OBJECTIVE DATA:

Review of the Systems (ROS)

            Vital Signs: Not provided

General: The patient denies fatigue, fever, or headache. Being uncomfortable while bearing weight

HEENT: Not provided

NECK: No details

Breasts: No Evidence

Respiratory: Not Provided

Cardiovascular/Peripheral Vascular: Not available

Gastrointestinal: Not available

Genitourinary: Not possible

Psychiatric: No information

Neurological: Patient is attentive and positioned to time and event

Skin: Not provided

Hematologic: No data provided

Endocrine: No information provided

Allergic/ Immunologic: No information regarding allergies available

ASSESSMENT:

                        Physical Exams and Diagnostic Tests

CBC – It helps to evaluate the entire groups of cells circulating in the blood to identify various diseases such as Leukemia, anemia, etc.

CMP– Acomprehensive metabolic panel (CMP) allows a clear analysis of the body’s chemical balance and metabolism. Theseresults would help determine the body’s electrolyte and fluid balance, sugar, glucose level, and organ function (Brahim, Fourer, Vigneron, & Maaref, 2019).

CBC-Slightly elevated WBC with a shift…Please click the icon below to purchase full answer at only $10