course material

1. Assessing Neurological Symptoms Essay Example Paper
Assessing Neurological Symptoms Essay Example PaperSUBJECTIVE DATA Chief Complaint
(CC): Left sided facial droop and reduced sense of smell.History of Present Illness (HPI): NM,
a 22-year-old African American woman, visited the clinic because she was concerned about
a slanting of her left side of the mouth when she smiled. She reports that when she smiles,
the left side of her mouth is angled, and she realized this when she woke up today and
looked in the mirror. She said that she had been suffering from headaches on and off for the
last several days, and that since she had begun cleaning her teeth, her sense of taste had also
diminished.ORDER A PLAGIARISM-FREE PAPER HEREMedications: NoneAllergies: NKAPast
Medical History (PMH): AsthmaPast Surgical History (PSH): Denies past
surgeriesSexual/Reproductive History: Menarche age 13. Heterosexual. LMP 4 weeks
agoPersonal/Social History: Denies tobacco, alcohol or illicit drug use. Reports eating a
healthy diet and exercises 4-5 times a week.Immunization History: immunizations up to
date. Flu shot not current.Significant Family History: Father - diabetesMother – high
cholesterolSister - HealthyReview of Systems (ROS)General: Denies fever, headache, chills
or night sweats. Denies fatigue or recent weight loss.Cardiovascular/Peripheral Vascular:
Denies chest pain, edema, or palpitations.Respiratory: Denies shortness of breath, cough, or
wheezing. Neuro: Denies dizziness, headaches, or vertigo Psych: Denies anxiety or
depressionOBJECTIVE DATA Physical Exam: Vital signs: BP 118/79, HR 78, RR 16, Temp 37.
1 C, SpO2 98%, Ht. 5ft 3in, Wt 146, BMI 23.6.General: alert and oriented x3. Left facial droop
noted. Well-dressed with appropriate grooming. Clear and coherent
speech.HEENT: Normocephalic and atraumatic head. Left facial droop noted. Intact visual
acuity, PERRLA. TMS pearly grey and intact. Nasal mucosa is moist and pink. Pink pharynx,
no edema or exudates. Skin: Skin is warm and dry, no rash or
lesionsCardiovascular/Peripheral Vascular: S1, S2 clear to auscultation, no gallops, rubs, or
murmurs. No edemaRespiratory: Lung sounds clear to auscultation, no cough or
wheezeNeurological: Positive for paresis on left side of face. DTR’s intact. CN II – XII grossly
intact.Diagnostic Test/Labs: · CBC· Electroneurography/EMG· MRI and CT
scanNIH Stroke Scale ASSESSMENT:Differential diagnosis Bell’s Palsy: This is a disorder in
which the muscles on one side of the face experience abrupt and severe weakening. The
weakening gives the appearance that half of the face is sagging (Somasundara & Sullivan,
2017). When someone smiles, just one side of their mouth moves, and the eye on the
unmoved side resists shutting.Guillain-Barre Syndrome: This condition is characterized by
the immune system of the body attacking the nervous system. Typically, the first symptoms

2. to appear are a feeling of numbness and weakness in the hands and feet. These feelings may
swiftly spread throughout the body and possibly paralyze it completely (Andary,
2017).Stroke: This disorder manifests itself either when a blood artery in the brain bursts
and bleeds, or when there is an obstruction in the blood flow that leads to the brain. Blood
and oxygen are unable to reach the tissues of the brain because of the rupture or the
obstruction. A stroke results in facial drooping and partial facial paralysis, and also
drooping of the eyes and lips (Alwood & Dossani, 2020).Lyme disease: Facial palsy may be
caused by an infection that is transmitted by a tick bite. Lyme disease is characterized by a
unique skin rash, as well as other symptoms such as fever, headache, and weariness
(Cardenas-de la Garza et al., 2018). Eventually, the illness will move to the
nerves.Hemiplegic migraine: This uncommon kind of migraine may induce temporary
paralysis on one side of the body, as well as weakness, tingling, and numbness on the
affected side of the body (Kumar et al., 2018).ORDER HEREReferences Alwood, B. T., &
Dossani, R. H. (2020). Vertebrobasilar Stroke. In StatPearls [Internet].
https://europepmc.org/books/nbk556084Andary, M. (2017). Guillain-Barre Syndrome.
https://emedicine.medscape.com/article/315632-overviewCardenas-de la Garza, J. A., De la
Cruz-Valadez, E., Ocampo-Candiani, J., & Welsh, O. (2018). Clinical spectrum of Lyme
disease. European Journal of Clinical Microbiology & Infectious Diseases, 38(2), 201-208.
https://doi.org/10.1007/s10096-018-3417-1Kumar, A., Samanta, D., Emmady, P. D., &
Arora, R. (2018). Hemiplegic migraine.
https://europepmc.org/books/nbk513302Somasundara, D., & Sullivan, F. (2017).
Management of Bell's Palsy. Australian Prescriber, 40(3), 94-
96. https://doi.org/10.18773/austprescr.2017.030Episodic/Focused SOAP Note
Template Patient Information:Initials, Age, Sex, RaceS.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: headOnset: 3 days agoCharacter: pounding, pressure
around the eyes and templesAssociated signs and symptoms: nausea, vomiting,
photophobia, phonophobiaTiming: after being on the computer all day at
workExacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not
completely betterSeverity: 7/10 pain scaleCurrent 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 neededSoc
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 -

3. 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.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
Assessing Neurological Symptoms Essay Example Paper.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.BUY
YOUR PAPER HEREO.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.Diagnostic results:
Include any labs, x-rays, or other diagnostics that are needed to develop the differential
diagnoses (support with evidenced and guidelines) Assessing Neurological Symptoms Essay
Example PaperA.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.P. This section is not
required for the assignments in this course (NURS 6512) but will be required for future
courses.ReferencesYou 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 7th edition
formatting.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 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

4. 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 Assessing Neurological Symptoms Essay
Example Paper.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. Week 1 Assignment- Case Study- Assessing Neurological Symptoms 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.
You will be making up the information that is missing to complete this soap note. ***Below
is the case study to use for this assignment:*** Case Study 3: Facial Droop 22 year old
African American female looks in the mirror and notices the left side of her mouth is slanted
when she smiles. She notes she has had some headache off and on a few days. Her taste has
decreased as well when she started brushing her teeth Assessing Neurological Symptoms
Essay Example Paper