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.
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.
CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS
In this Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
Case Study 1: Headaches
A 40 year old female presents with complaint of a headache for one week. Reports a head cold 3 weeks ago. Thought it was getting better, but sinus symptoms are back and even worse.
Describes the headache is located across her forehead; feels like pressure behind my eyes and unable to breathe out of nose. Also feels mucus running down the back of throat. Pain sometimes severe (8/10) but with acetaminophen reduces to moderate (4/10) and occasionally mild (2/10). Occasional nonproductive cough. Feels feverish at times; noted frequent sneezing and no appetite. Bending over seems to make the headache worse. Acetaminophen improves my headache, but doesnt take it away. Taking Sudafed HCL 120 mg every 12 hours, with some relief. Symptoms are worse in the morning awakes with a headache. Ranges from 2/10 at its best to 8/10. Difficulty with concentrating at job and feels very tired
FOCUS IS THE NEUROLOGICAL SYSTEM
NURS_6512_Week_9_Assignment1_Rubric
NURS_6512_Week_9_Assignment1_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeUsing 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.
50 to >44.0 pts
Excellent
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.
44 to >38.0 pts
Good
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.
38 to >32.0 pts
Fair
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.
32 to >0 pts
Poor
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.
50 pts
This criterion is linked to a Learning Outcome· List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
35 to >29.0 pts
Excellent
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.
29 to >23.0 pts
Good
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.
23 to >17.0 pts
Fair
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.
17 to >0 pts
Poor
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.
35 pts
This criterion is linked to a Learning OutcomeWritten 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 to >4.0 pts
Excellent
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 to >3.0 pts
Good
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 to >2.0 pts
Fair
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.
2 to >0 pts
Poor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided. 5 pts This criterion is linked to a Learning OutcomeWritten Expression and Formatting - English writing standards: Correct grammar, mechanics, and proper punctuation 5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.
4 to >3.0 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
3 to >2.0 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.
2 to >0 pts
Poor
Contains many (= 5) grammar, spelling, and punctuation errors that interfere with the readers understanding.
5 pts
This criterion is linked to a Learning OutcomeWritten 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 to >4.0 pts
Excellent
Uses correct APA format with no errors.
4 to >3.0 pts
Good
Contains a few (1 or 2) APA format errors.
3 to >2.0 pts
Fair
Contains several (3 or 4) APA format errors.
2 to >0 pts
Poor
Contains many (= 5) APA format errors.
5 pts
Total Points: 100
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