NURS 6512 Week 9 Assessment of Cognition and the Neurologic System

Sample Answer for NURS 6512 Week 9 Assessment of Cognition and the Neurologic System Included After Question

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.

By Day 6 of Week 9

Submit your Assignment.

Submission and Grading Information

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• Please save your Assignment using the naming convention “WK9Assgn1+last name+first initial.(extension)” as the name.
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• If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
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Grading Criteria

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• ·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.

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A Sample Answer For the Assignment: NURS 6512 Week 9 Assessment of Cognition and the Neurologic System

Title: NURS 6512 Week 9 Assessment of Cognition and the Neurologic System

Patient Information:

Initials: K.L.               Age: 40 years old                    Sex: Female                Race: Caucasian

S.

CC (chief complaint): Case Study 1: Headache

HPI: K.L., a 40-year-old Caucasian woman, complains of a headache she’s had for a week. She mentions having a “head cold” three weeks ago.  She adds that she thought things were improving, but her sinus issues have returned and are growing worse. She says the pain is across her forehead, feels like tension behind her eyes, and prevents her from breathing via her nose. The posterior part of her throat is also filled with mucous, she notices.  She asserts that acetaminophen lessens the pain from being occasionally severe (8/10) to being moderate (4/10) and sporadically mild (2/10).  Additionally, she mentions sporadic nonproductive coughing.  She reports experiencing occasional fevers, frequent sneezing, and a lack of appetite. She claims that bending over seemed to aggravate her headache. Additionally, she takes 120 mg of Sudafed HCL every 12 hours, which offers some comfort. She asserts that she awakes with a headache and that her manifestations are worse in the morning. She claims that the pain is between 2/10 at its best and 8/10 at its worst. She also mentions having trouble focusing at work and feeling quite exhausted.

Location: Forehead

Onset: 3 weeks ago

Character: feels like tension behind her eyes, and prevents her from breathing via her nose

Associated signs and symptoms: sporadic nonproductive coughing, fevers, frequent sneezing, and a lack of appetite.

Timing: worse in the morning

Exacerbating/ relieving factors: acetaminophen lessens the pain from being occasionally severe (8/10) to being moderate (4/10) and sporadically mild (2/10). bending over seemed to aggravate her headache

Severity: pain is between 2/10 at its best and 8/10 at its worst

Current Medications:

• Acetaminophen 1300mg orally after every 8 hours PRN
• Sudafed HCL 120 mg every 12 hours

Allergies: none

PMHx:

• Confirms having had chickenpox as a kid in the past.
• Immunization status: All vaccines are current, with the most recent being a 3-year-old tetanus dose.
• Denies having any prior surgical procedures.
• Hospitalization: She strongly denies having ever been in a hospital.

Soc Hx: The patient is presently a student in an economics master’s degree. She works for a financial company and has done so for the previous six years. She’s been married to the same person for the last five years. She and their two boys reside in Florida with her boyfriend. The catholic she is. She works out frequently and makes an effort to eat a healthy diet. She admits to occasionally drinking wine, but only on special occasions. denies using cigarettes or any other addictive substance.

Fam Hx: At 81 years old, the father is still alive and treating coronary artery disease, HTN, and skin cancer. Mother passed away from breast cancer at the age of 71. All of the grandparents died without any known health issues. The patent only has one sibling, a 55-year-old who is dealing with CVA.

ROS:

GENERAL: There were no complaints of weariness, chills, sweating during the night, or weight changes.

HEENT: symptoms include a headache, eye pressure, difficulty breathing through the nose, throat mucous, intermittent but ineffective coughing, persistent sneezing, and lack of appetite.

SKIN: There are no rashes or sores, and the skin is warm and healthy.

CARDIOVASCULAR: The heart rate is normal. There were no further heartbeats or murmurs heard.

RESPIRATORY: The patient occasionally coughs ineffectively.

GASTROINTESTINAL: There were no reports of stomach aches, nausea, or vomiting.

GENITOURINARY: There were no complaints of urinary urgency, burning, or frequency.

NEUROLOGICAL: Reports symptoms include a headache and eye pressure. She says the pain is across her forehead and feels like tension behind her eyes.

MUSCULOSKELETAL: There were no reports of joint discomfort, muscular weakness, or muscle pain.

HEMATOLOGIC: There was no evidence of lymphadenopathy.

LYMPHATICS: There was no pronounced swelling of the lymph nodes.

PSYCHIATRIC: There were no reported mood swings, suicidal thoughts, or anxiety.

 

O.

Physical exam:

Vitals: BP 127/98; P 77; T 99.6; R 20 PsaO₂ 99% room air. Ht 5’7 Wt 159 BMI: 24.90

General: The patient exhibits signs of discomfort but seems well-nourished and developed.

Neurological: Awake and completely alert. The patient denies having numbness and tingling in both his lower and upper extremities. Reports throbbing unilateral headache in the frontal area ranging from 2 to 8/10. Denies aura and has difficulty walking. Both short-term and long-term memory are intact. Normal gait. Gross and fine motor abilities are both intact. Cranial nerves I-X are unaffected.

Diagnostic results: To help rule out an infection and assess for anemia, which can induce headaches, a complete blood count (CBC) may be prescribed. To check for structural irregularities or signs of trauma, a CT scan or other head imaging investigation may be required. MRI may be needed to rule out further headache reasons, such as brain tumors. (EEG) Electroencephalogram. To exclude any neurological or seizure conditions, an electroencephalogram (EEG) may be performed.

A.

Differential Diagnoses:

1. Migraine Headache: The patient reported having migraines for a week, describing the pain as varying from 2 to 8 on a scale of 10, worst in the morning, and alleviated by acetaminophen (Gupta & Gaurkar, 2022).These symptoms fit the description of migraine headaches, a neurological condition that can produce frequent, severe headaches along with additional symptoms including nausea and sound and light sensitivity (Gupta & Gaurkar, 2022). The individual’s age and sex, together with the existence of several other symptoms, all support this diagnosis.
2. Cluster headache: Severe, persistent headaches that come in clusters are the hallmark of cluster headaches. They generally are orbital (occurring around or behind the eyes) and unilateral (occurring on one side of the head) (Ray et al., 2022). Conjunctival injection, congestion in the nose, rhinorrhea, and facial sweat are among the symptoms that are often present. They can last for anywhere between 15 minutes and three hours (Ray et al., 2022). Given her advanced age and a history of cluster headaches, the woman in this case exhibits many of the classic symptoms of the condition. Additionally, the patient claims that using acetaminophen reduces their pain from 8/10 to 4/10, which is similar to other cluster headache therapies including triptans, oxygen, and steroids (Ray et al., 2022).
3. Tension Headache: Patients who complain of headaches frequently have tension headaches investigated as a diagnosis. It is a common headache disease characterized by heightened head, neck, and scalp muscular tension. It frequently has a bilateral distribution and a dull, painful, or pressure-like feeling. It may cause a sense of stiffness in the neck and head muscles and range in severity from moderate to severe (Mansoureh Togha et al., 2022). Tension headache is a possible diagnosis based on the individual’s medical history and physical examination results. The patient’s account of the headache is in line with the tension headache criteria, and the observation that acetaminophen provides relief from the pain further supports this diagnosis.
4. Acute Sinusitis: The patient has been complaining of loss of appetite for the last week as well as headaches, nasal congestion, mucus running down the throat, occasional nonproductive coughing, and constant sneezing. Acute sinusitis is diagnosed based on these symptoms and indications. According to Patel et al. (2018), a bacterial or viral infection is frequently the cause of a sinus infection. The individual’s observation that her complaints worsen in the morning when she wakes up with a headache while acetaminophen lessens but does not cure the headache supports a sinus infection even more.
5. Allergic Rhinitis: The patient had a headache, tension behind her eyes, difficulty breathing through her nose, mucus in her throat, sporadic but continuous coughing, and a lot of sneezing. These signs and symptoms support the diagnosis of allergic rhinitis (Nur Husna et al., 2022). Allergic rhinitis, which can range in severity from moderate to severe, is an inflammation in the nasal passages brought on by allergens. A physical examination with findings of conjunctival erythema, erythematous and inflamed nasal mucosa, and clear mucopurulent discharge are consistent with allergic rhinitis even if the patient has not previously reported any allergies.

 

References

Gupta, J., & Gaurkar, S. S. (2022). Migraine: An Underestimated Neurological Condition Affecting Billions. Cureus. https://doi.org/10.7759/cureus.28347

Mansoureh Togha, Jafari, E., Ansari, H., Haghighi, S., & Seyed Ehsan Mohammadianinejad. (2022). Headache and Migraine in Practice. Academic Press.

Nur Husna, S. M., Tan, H.-T. T., Md Shukri, N., Mohd Ashari, N. S., & Wong, K. K. (2022). Allergic Rhinitis: A Clinical and Pathophysiological Overview. Frontiers in Medicine, 9. https://doi.org/10.3389/fmed.2022.874114

Patel, Z. M., & Hwang, P. H. (2018). Acute Bacterial Rhinosinusitis. Infections of the Ears, Nose, Throat, and Sinuses, 133–143. https://doi.org/10.1007/978-3-319-74835-1_11

Ray, J. C., Stark, R. J., & Hutton, E. J. (2022). Cluster headache in adults. Australian Prescriber, 45(1), 15–20. https://doi.org/10.18773/austprescr.2022.004