NURS 6512 Assignment 1: Case Study Assignment: Assessing Neurological Symptoms
CASE STUDY 1: Headaches
NURS 6512 Assignment 1. 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 NURS 6512 Assignment 1, 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 NURS 6512 Assignment 1. 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.NURS 6512 Assignment 1
NURS 6512 Assignment 1 Answer
Case 1: Headaches
Patient Information: A 20-year-old man
Subjective Data:
Chief Complaint: Intermittent headaches
History of Present Illness (HPI): The patient reports experiencing intermittent headaches that diffuse all over the head, with more intense pain around the jaw, cheekbone, nose, and above the eyes.
Medications: No documented history of medication use.
Allergies: The patient has no known allergies to drugs, food, or environmental factors.
Past Medical History (PMH): Past medical history is not available.
Past Surgical History (PSH): Surgical history information is not provided.
Social History: There is no social history available.
Immunization History: Immunization history is not provided.
Significant Family History: Family history information is not known.
Lifestyle: The patient’s lifestyle details are not available.
Objective Data:
Review of Systems (ROS):
Vital Signs: Vital signs have not been provided.
General: The patient denies fatigue, fever, or headache but reports discomfort while bearing weight.
HEENT: Specific HEENT details are not provided.
Neck: No neck-related information is available.
Breasts: No breast-related evidence is provided.
Respiratory: Respiratory details are not available.
Cardiovascular/Peripheral Vascular: Cardiovascular and peripheral vascular information is not provided.
Gastrointestinal: Information about the gastrointestinal system is not available.
Genitourinary: Genitourinary information is not possible.
Psychiatric: There is no information related to the psychiatric system.
Neurological: The patient is attentive and oriented to time and event.
Skin: Specific skin information is not provided.
Hematologic: Hematologic data has not been provided.
Endocrine: Information related to the endocrine system is not available.
Allergic/Immunologic: No information regarding allergies or immunologic history is provided.
Assessment:
Physical Exams and Diagnostic Tests:
CBC (Complete Blood Count) – This test helps evaluate the various types of blood cells, aiding in the identification of diseases such as leukemia and anemia (Brahim, Fourer, Vigneron, & Maaref, 2019).
CMP (Comprehensive Metabolic Panel) – This panel provides a comprehensive analysis of the body’s chemical balance and metabolism. It assesses electrolyte and fluid balance, sugar and glucose levels, and organ function (Brahim, Fourer, Vigneron, & Maaref, 2019).
CBC results indicate a slightly elevated white blood cell count with a shift…
Reference:
Brahim, T., Fourer, J., Vigneron, J. P., & Maaref, M. A. (2019). How to Interpret Blood Test Results. In Atlas of Diagnostic Cytopathology (pp. 9-30). Springer.
