Case Study For Assessing Neurological Symptoms Discussion

Case :
Asia brings her 67year old father into the office stating he is very forgetful. He has lost his car keys several times. She also states he has driven to the store and called her asking for directions to get back home.

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. Case Study For Assessing Neurological Symptoms Discussion

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Patient Information:

M.P, 67, Male, Caucasian

CC: “Forgetfulness”

HPI: M.P is a 67-year-old Caucasian male brought to the clinic by his daughter who reports that he has become very forgetful. He has misplaced his keys on many occasions. Furthermore, she claims he drove to the store and contacted her for directions on how to get home.

Current Medications: Atorvastatin 20 mg once daily, Lisinopril 10 mg once daily

Allergies: NKA

PMHx: Hyperlipidemia, hypertension

Soc Hx: Lives with her daughter. Reports drinking alcohol occasionally. Denies tobacco or illicit drugs use.

Fam Hx: Mother: died of breast cancer, Father: hypertension, Brother: Alcoholism

ROS:

GENERAL: Denies weight loss, fever, chills, weakness or fatigue.

CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. Reports occasional palpitations and edema in both legs.

GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: Reports being forgetful. Denies dizziness, syncope or loss of balance.

PSYCHIATRIC: Denies history of depression or anxiety.

Vital Signs: BP: 148/92, HR: 89, RR: 18, Temp: 98.2, O2 sat: 98%, Height: 5’8”, Weight: 212 lbs Case Study For Assessing Neurological Symptoms Discussion

Physical exam:

General: Pleasant and in no acute distress. A&O x3, with periods of confusion. Well-dressed and well-groomed.

Cardiovascular: S1, S2 clear to auscultation, no murmurs or gallops. Positive for bilateral 2+ LE edema is noted.

Gastrointestinal: The abdomen is flat and soft. No distention. Bowel sounds present in all quadrants. No masses noted.

Neurologic: CNS II-XII grossly intact

Diagnostic results:

PET scan – plaques consisting of amyloid- β peptides noted in the brain.

Kokmen Short Test for Mental Status (STMS) – 23/38

Mini-Mental State Exams (MMSE) – 22/30

Differential Diagnoses

Alzheimer’s disease: This is a mental disorder that most commonly causes of dementia. The buildup of amyloid plaques and neurofibrillary tangles in the brain is the root cause of this disease (Weller & Budson, 2018). People with Alzheimer’s disease often experience cognitive impairment, forgetfulness, as well as a diminished sense of independence, which may lead them to become disoriented even in familiar environments. According to the patient’s daughter, he often loses his keys and asks for help in finding his way back home.

Dementia: This is a chronic condition that causes memory loss over time. Dementia patients often show signs of deterioration in areas such as temperament, dexterity, executive functioning, speech, and even complicated reasoning (Emmady & Tadi, 2021). The patient is displaying indicators of forgetfulness, which may indicate a reduction in cognitive ability and memory.

Cognitive Impairment: cognitive impairment is characterized by a decline in mental abilities such as memory, learning, attention, and judgment. It strikes the elderly often and worsens with time. This is a problem when mood disorders like depression are suspected to cause cognitive alterations (Perini et al., 2019). There are indicators of cognitive deterioration in the patient, but his mood has not changed.

Delirium: Delirium refers to a severe kind of confusion that often affects the elderly. Forgetfulness is a hallmark of this condition, which is caused by either a shift in awareness or a failure to maintain concentration (Echeverra & Paul, 2021). The patient seemed to be fully cognizant during the conversation, despite moments of apparent confusion.

References

Echeverría R. & Paul M. (2021). Delirium. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK470399/

Emmady P.D & Tadi P. (2021). Dementia. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK557444/

Perini, G., Cotta Ramusino, M., Sinforiani, E., Bernini, S., Petrachi, R., & Costa, A. (2019). Cognitive impairment in depression: recent advances and novel treatments. Neuropsychiatric disease and treatment, 15, 1249–1258. https://doi.org/10.2147/NDT.S199746

Weller, J., & Budson, A. (2018). Current understanding of Alzheimer’s disease diagnosis and treatment. F1000Research, 7, F1000 Faculty Rev-1161. https://doi.org/10.12688/f1000research.14506.1 Case Study For Assessing Neurological Symptoms Discussion

Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. Case Study For Assessing Neurological Symptoms Discussion

Example of Complete ROS:

GENERAL: Denies weight loss, fever, chills, weakness or fatigue.

HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN: Denies rash or itching.

CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: Denies shortness of breath, cough or sputum.

GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC: Denies anemia, bleeding or bruising.

LYMPHATICS: Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC: Denies history of depression or anxiety.

ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

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Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)Case Study For Assessing Neurological Symptoms Discussion

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7^th edition formatting.