Make a SOAP Note Not a narrative essay: Assessing Neurological Symptoms
Note: Your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to the Comprehensive SOAP Template in the attachments below for guidance.
CASE: Numbness and Pain
A 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.
To prepare:
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.
Address all these in the SOAP Note not an Narrative Essay (Follow the SOAP Note Template on the attachment):
1. A description of the health history you would need to collect from the patient in the case study to which you were assigned.
2. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.
3. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
REMINDER:Please make a SOAP NOTE for this case. Make your own patient’s data, applicable health history, review of systems, P.E., labs, differential diagnosis, final diagnosis etc. Incorporate the data from the case in the SOAP note that you will do… This is not a narrative essay ok…. I need SOAP note (Nurse Practitioner/RN/MD makes SOAP note)… Be guided with the SOAP Note in the template… Don’t copy paste. Formulate your own… Don’t forget to cite the Five Differential diagnosis and have Reference lists too. Rank the differential diagnosis from most to least likely… Expand more your ideas in explaining the diagnosis not only one or two sentences. Justify them correctly and briefly.
Resources:
· Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
o Chapter 5, “Mental Status” (64-78)
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.
o Chapter 22, “Neurologic System” (pp. 544-580)
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. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
o Chapter 4, “Affective Changes” (pp. 33-46)
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.
o Chapter 9, “Confusion in Older Adults” (pp. 97-109)
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.
o Chapter 13, “Dizziness” (pp. 148-157)
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.
o Chapter 19, “Headache” (pp. 221-234)
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.
o Chapter 28, “Sleep Problems” (pp. 345–355)
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. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
o Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”; p. 26)
o Chapter 3, “Adult Preventative Care Visits” (“Assessing Geriatric Risk Factors”; pp. 50–55)
o Chapter 4, “Pediatric Preventative Care Visits” (” Neurological Reflexes Tthat Should Be Tested During Infancy”; (p. 79)
o Chapter 10, “Prescription Writing and Electronic Prescribing” (pp. 207–-223)
Note: Download and review these Adult Examination Checklists and Physical Exam Summary to use during your practice neurological examination.
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for mental assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Mental Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for neurologic assessment. In Mosby’s guide to physical examination(7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Neurologic Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Neurologic system. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Neurologic System Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· 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.
· Lonie, J. A., Tierney, K. M., & Ebmeier, K. P. (2009). Screening for mild cognitive impairment: A systematic review. International Journal of Geriatric Psychiatry, 24(9), 902–915.
This study seeks to review the use of cognitive screening instruments for mild cognitive impairment. The authors also discuss the limitations of cognitive screening instruments.
· University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved fromhttp://www.med-ed.virginia.edu/courses/rad/index.html
This website provides an introduction to radiology and imaging. For this week, focus on head CTs in neuroradiology.
Media
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 5 and 22 that relate to the assessment of cognition and the neurologic system. Refer to the Week 4 Learning Resources area for access instructions.
Optional Resources
· LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowin’s diagnostic examination (9th ed.). New York, NY: McGraw Hill Medical.
o 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.
o 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.
