CASE STUDY 2:Week 9: Assessment of Cognition and the Neurologic System

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CASE STUDY 2:Week 9: Assessment of Cognition and the Neurologic System

Case Study Assignments – To create a focused/episodic note, you must make up information for all aspects.

CASE Study:

“A 48-year-old male with a history of diabetes mellitus type 2 complains of not being able to feel his toes in the left foot. He also complains of numbness in the heel of the right foot and a tingling sensation.”

 

To PrepareBy 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 AssignmentUse 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

To submit your completed Assignment for review and grading, do the following:Rubric Detail Select Grid View or List View to change the rubric’s layout.

Name: NURS_6512_Week_9_Assignment1_RubricGrid View

List View               Excellent  Good       Fair          PoorUsing 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: 100Name: NURS_6512_Week_9_Assignment1_RubricLearning ResourcesRequired Readings (click to expand/reduce) 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.  Â·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. Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center. Chapter 4, “Affective Changes” 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.

Chapter 9, “Confusion in Older Adults” 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.

Chapter 13, “Dizziness” 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. Chapter 19, “Headache” 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. Chapter 31, “Sleep Problems” 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. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis. Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5)Note: Download the Physical Examination Objective Data Checklist to use as you complete the Comprehensive (Head-to-Toe) Physical Assessment assignment. Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical examination objective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance Center. Note: Download and review the Student Checklists and Key Points to use during your practice neurological examination. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Mental status: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Kim, H., Lee, S., Ku, B. D., Ham, S. G., & Park, W. (2019). Associated factors for cognitive impairment in the rural highly elderly. Brain and Behavior, 9(5), e01203. https://doi.org/10.1002/brb3.1203 Lee, K., Puga, F., Pickering, C. E., Masoud, S. S., & White, C. L. (2019). Transitioning into the caregiver role following a diagnosis of Alzheimer’s disease or related dementia: A scoping review. International Journal of Nursing Studies, 96, 119–131. https://doi.org/10.1016/j.ijnurstu.2019.02.007 O’Caoimh, R., & Molloy, D. W. (2019). Comparing the diagnostic accuracy of two cognitive screening instruments in different dementia subtypes and clinical depression. Diagnostics, 9(3), 93. https://doi.org/10.3390/diagnostics9030093 Shadow Health Support and Orientation ResourcesUse the following resources to guide you through your Shadow Health orientation as well as other support resources: Shadow Health. (2021). Welcome to your introduction to Shadow Health. https://link.shadowhealth.com/Student-Orientation-Video Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us  Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students. https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide Document: DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment (Word document) Use this template to complete your Assignment 3 for this week. Optional ResourcesLeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical. Chapter 14, “The Neurologic Examination”  This chapter provides an overview of the nervous system. The authors also explain the basics of neurological exams.Chapter 15, “Mental Status, Psychiatric, and Social Evaluations”  In this chapter, the authors provide a list of common psychiatric syndromes. The authors also explain the mental, psychiatric, and social evaluation process.Required Media (click to expand/reduce)

Assignment 1: Case Study Assignment: Assessing Neurological Symptoms Photo Credit: Getty Images/iStockphoto 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 AssignmentUse 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 9Submit your Assignment.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following: Please save your Assignment using the naming convention “WK9Assgn1+last name+first initial.(extension)” as the name.Click the Week 9 Assignment 1 Rubric to review the Grading Criteria for the Assignment. This  is a focused  soap note

 

 

I don’t know how many pages it will be. Just need appropriate information 

 

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