A 70-year-old female comes to your clinic with complaints of forgetfulness<\/p>\n
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\\\u2019s quality of living. Accurately assessing neurological symptoms is a complex process that involves the analysis of many factors.<\/p>\n
In this Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.<\/p>\n
To Prepare
\nBy Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the \u201cCourse Announcements\u201d section of the classroom for your assignment from your Instructor.
\nAlso, 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.<\/p>\n
With regard to the case study you were assigned:<\/p>\n
Review this week\\\u2019s Learning Resources, and consider the insights they provide about the case study.
\nConsider what history would be necessary to collect from the patient in the case study you were assigned.
\nConsider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\\\u2019s condition. How would the results be used to make a diagnosis?
\nIdentify at least five possible conditions that may be considered in a differential diagnosis for the patient.<\/p>\n
The Case Study Assignment<\/p>\n
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\\\u2019s differential diagnosis, and justify why you selected each<\/p>\n
Case study 3: Forgetfulness<\/p>\n
A 70\u2013year\u2013old female comes to your clinic with complaints of forgetfulness. She noticed it about a year ago and it has progressively gotten worse. She sometimes forgets what she is going to do when she gets to another room. Her family has noticed the problem with her forgetfulness but she is still able to manage her finances and drive, per her report.<\/p>\n
Episodic\/Focused SOAP Note Template<\/p>\n
Patient Information:<\/p>\n
Initials, Age, Sex, Race<\/p>\n
S.<\/p>\n
CC (chief complaint) a BRIEF statement identifying why the patient is here \u2013 in the patient\u2019s own words \u2013 for instance \u201cheadache\u201d, NOT \u201cbad headache for 3 days\u201d.<\/p>\n
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 \u201cheadache\u201d, the LOCATES for the HPI might look like the following example:<\/p>\n
Location: head<\/p>\n
Onset: 3 days ago<\/p>\n
Character: pounding, pressure around the eyes and temples<\/p>\n
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia<\/p>\n
Timing: after being on the computer all day at work<\/p>\n
Exacerbating\/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better<\/p>\n
Severity: 7\/10 pain scale<\/p>\n
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.<\/p>\n
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).<\/p>\n
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<\/p>\n
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 \u2013 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.<\/p>\n
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.<\/p>\n
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.<\/p>\n
Example of Complete ROS:<\/p>\n
GENERAL: No weight loss, fever, chills, weakness or fatigue.<\/p>\n
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.<\/p>\n
SKIN: No rash or itching.<\/p>\n
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.<\/p>\n
RESPIRATORY: No shortness of breath, cough or sputum.<\/p>\n
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.<\/p>\n
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM\/DD\/YYYY.<\/p>\n
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.<\/p>\n
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.<\/p>\n
HEMATOLOGIC: No anemia, bleeding or bruising.<\/p>\n
LYMPHATICS: No enlarged nodes. No history of splenectomy.<\/p>\n
PSYCHIATRIC: No history of depression or anxiety.<\/p>\n
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.<\/p>\n
ALLERGIES: No history of asthma, hives, eczema or rhinitis.<\/p>\n
O.
\nPhysical 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 \u201cWNL\u201d or \u201cnormal.\u201d You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.<\/p>\n
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)<\/p>\n
A.
\nDifferential 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>\n
P.
\nThis section is not required for the assignments in this course (NURS 6512) but will be required for future courses.<\/p>\n
References
\nYou 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 6th edition formatting.<\/p>\n
Expert Answer and Explanation<\/p>\n
SOAP Note<\/p>\n
Patient Information:<\/p>\n
Patient Information:
\nS, 70 years old, Female, Unknown race<\/p>\n
CC: Forgetfulness
\nHPI: The patient is a 70-year-old female who has been experiencing forgetfulness for about a year. She reports that it has progressively gotten worse, and she sometimes forgets what she is going to do when she gets to another room. Her family has noticed the problem with her forgetfulness, but she is still able to manage her finances and drive.<\/p>\n
Location: Memory
\nOnset: Gradual, over the past year
\nCharacter: Progressive forgetfulness, difficulty remembering things
\nAssociated signs and symptoms: None reported
\nTiming: Occurs daily, more frequently in recent months
\nExacerbating\/Relieving factors: None reported
\nSeverity: Moderate, affects daily activities<\/p>\n
Current Medications: None reported
\nAllergies: None reported
\nPMHx: Unknown<\/p>\n
Physical Exam:
\nMental status examination to assess cognitive function and memory
\nNeurological examination to assess for any signs of neurological impairment<\/p>\n
Diagnostic Tests:
\nMRI or CT scan of the brain to assess for any structural abnormalities
\nLaboratory tests such as thyroid function tests, vitamin B12 and folate levels, and a complete blood count to rule out any metabolic causes of forgetfulness
\nNeuropsychological testing to evaluate cognitive function and memory<\/p>\n
Differential Diagnosis:
\nMild Cognitive Impairment
\nDementia (Alzheimer’s disease)
\nDepression
\nVitamin B12 or folate deficiency
\nThyroid dysfunction
\nBased on the patient’s history and physical examination, a thorough evaluation including diagnostic tests and neuropsychological testing would be appropriate to gather more information about the patient’s condition and make a diagnosis. The differential diagnosis includes conditions such as mild cognitive impairment, dementia, depression, vitamin B12 or folate deficiency, and thyroid dysfunction. Further evaluation and testing will be necessary to confirm or rule out any of these possible conditions.<\/p>\n","protected":false},"excerpt":{"rendered":"
A 70-year-old female comes to your clinic with complaints of forgetfulness 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\\\u2019s […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1301,271,405,452],"tags":[1303,828],"class_list":["post-2425","post","type-post","status-publish","format-standard","hentry","category-writing-a-soap-note-sample-answers","category-nursing-assignment-help","category-soap-note-assignment-help","category-write-my-nursing-assignment-paper","tag-a-70-year-old-female-comes-to-your-clinic-with-complaints-of-forgetfulness","tag-homework-help"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/posts\/2425","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/comments?post=2425"}],"version-history":[{"count":0,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/posts\/2425\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/media?parent=2425"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/categories?post=2425"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/tags?post=2425"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}