​​Week 9: Assessment of Cognition and the Neurologic System

A 63-year-old woman comes to your office because she’s been forgetting things…a young mother comes in concerned because her baby fails to make eye contact and is unresponsive to touch…a teenager comes in and a parent complains that the teen obsessively washes his hands.

An array of neurological conditions could be causing the above symptoms. When assessing the neurologic system, it is vital to formulate an accurate diagnosis as early as possible to prevent continued damage and deterioration of a patient’s quality of life.

This week, you will explore methods for assessing the cognition and the neurologic system.

​Learning Objectives

Students will:

  • Evaluate abnormal neurological symptoms
  • Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for cognition and the neurologic system
  • Assess health conditions based on a head-to-toe physical examination

 

​ssignment 1: 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.

​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.

 

CASES STUDY

A 33-year-old female comes to your clinic alarmed about sudden “drooping” on the right side of the face that began this morning. She complains of excessive tearing and drooling on her right side as well.

 

 

 

​By Day 6 of Week 9

 

​Rubric Detail

Select Grid View or List View to change the rubric’s layout.

​Content

​Name: NURS_6512_Week_9_Assignment1_Rubric

 

 

Excellent

Good

Fair

Poor

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.

Points Range: 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.

Points Range: 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.

Points Range: 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.

Points Range: 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.

Points Range: 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.

Points Range: 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.

Points Range: 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.

Points Range: 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.

Points Range: 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.

Points Range: 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.

Points Range: 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.

Points Range: 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

Points Range: 5 (5%) – 5 (5%)

Uses correct grammar, spelling, and punctuation with no errors.

Points Range: 4 (4%) – 4 (4%)

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

Points Range: 3 (3%) – 3 (3%)

Contains several (3 or 4) grammar, spelling, and punctuation errors.

Points Range: 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.

Points Range: 5 (5%) – 5 (5%)

Uses correct APA format with no errors.

Points Range: 4 (4%) – 4 (4%)

Contains a few (1 or 2) APA format errors.

Points Range: 3 (3%) – 3 (3%)

Contains several (3 or 4) APA format errors.

Points Range: 0 (0%) – 2 (2%)

Contains many (≥ 5) APA format errors.

 

 

 

 

 

USE THE BELOW TAMPLET EPISODIC/FOCUSE SOAP NOTE PLEASE

 

 

 

 

 

 

 

 

Episodic/Focused SOAP Note Exemplar 

Focused SOAP Note for a patient with chest pain

S. CC: â€œChest pain”  HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning.  The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms. 

 

Medications: Lisinopril 10mg, Omeprazole 20mg, Norvasc 5mg PMH: Positive history of GERD and hypertension is controlled FH: Mother died at 78 of breast cancer; Father at 75 of CVA.  No history of premature cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years 

 

Allergies: PCN-rash; food-none; environmental- none

 

Immunizations: UTD on immunizations, covid vaccine #1 1/23/2021 Moderna; Covid vaccine #2 2/23/2021 Moderna 

ROS    General–Negative for fevers, chills, fatigue Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema  Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis   

O.

VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”

 

General–Pt appears diaphoretic and anxious

Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the

second right inter-costal space which radiates to the neck.

A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted.

Gastrointestinal–The abdomen is symmetrical without distention; bowel

sounds are normal in quality and intensity in all areas; a

bruit is heard in the right para-umbilical area. No masses or

splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.

Pulmonary— Lungs are clear to auscultation and percussion bilaterally 

 

Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)

A.

 

 

Differential Diagnosis:

1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).

2) Angina (provide supportive documentation with evidence based guidelines).

3) Costochondritis (provide supportive documentation with evidence based guidelines).

4)Pericarditis (provide supportive documentation with evidence based guidelines).

5) Chest injury/Muscle strain (provide supportive documentation with evidence based guidelines).

 

 

Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction

 

 

 

P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. But you can write what you plan for you patient

 

Each relevant diagnosis is scored on a four-point scale:ï‚·Priority (1 point):the correct priority of the diagnosis was chosenï‚·Evidence (up to 2 points):the strength of the patient cue(s) selected as evidence for the identified diagnosis or Required Evidence: selecting at least one cue that directly indicates the presence of a problem or risk is worth 2 points Supporting Evidence: selecting at least one cue that is a contributing factor or cause of a problem or risk, without the presence of Required Evidence, is worth 1 pointï‚·Planning (1 point):the plan proposed to address the diagnosis includes at least one correct component 

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CASE STUDY 3: Drooping of Face A 33-year-old female comes to your clinic alarmed about sudden “drooping” on the right side of the face that began this morning. She complains of excessive tearing and drooling on her right side as well.

 

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.

 

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.

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