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Episodic/Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race


S.

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.

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.


O.

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)


A

.

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.

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 7th edition formatting.

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Health9

Episodic/Focused SOAP Note Template

Patient Information:

T.L., 47, Female, Caucasian

S.

CC: Pt has compliant of pain in her right wrist and tingling and numbness in her thumb, index,
and middle finger of the right hand.

HPI: T.L. is a 47 year old women that states that she has been having pain for the last two weeks
in her right wrist. while experiencing tingling and numbness in her thumb, middle, and index
finger on that hand. She states that the she has been dropping her hairstyling tools and it is
causing her frustration. She rates the pain as a 5/10.

Current Medications:

1. Ibuprofen 200mg PO PRN

Allergies:

1. Pt denies any medication, food, latex, or environmental allergies.

PMHx:

Pt is up to date on all her immunizations. Pt’s last tetanus shot was 3 years ago after stepping on
a rusty nail in her garage. Pt has no medical conditions, and has never been hospitalized. Pt
received her flu shot last year and got her COVID vaccinations, Moderna in May and June of
2021.

Soc Hx: T.L. works as a hairstylist at Europa Salon and Spa in Coralville Iowa. She works 10
hour days Wednesday through Saturday. She is divorced and has no children. Pt denies smoking
or drinking alcohol. Pt states she has never tried any illegal substances such as marijuana or
narcotics. Pt states she always wears her seat belts and has no concern for her safety. Pt denies
any depression or anxiety.

Fam Hx:

Mother: 69, Hypertension, Diabetes Mellitus Type 2

Father: Deceased at age 70, 2 years ago from lung cancer. Former smoker, COPD.

Maternal Grandmother: 92, hypertension

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Maternal Grandfather: deceased 3 years ago at age of 92. Died from heart failure. Hx of HTN

Paternal Grandmother: age 90, HTN DM 2

Paternal Grandfather: age 90, former smoker, COPD, HTN, Diastolic Heart failure.

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 any change in weight. Pt denies 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: Denies any burning with urination. Pregnancy. Last menstrual period,
07/03/2021.

NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia. No change in bowel
or bladder control. Pt states she has numbness and tingling in the fingers of her right hand.

MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness. Pt reports weakness,
tingling, and pain in her right hand. She denies any pain or numbness in her left hand. Pt states
she has decreased strength in her right hand and has been dropping things.

HEMATOLOGIC: Denies anemia, bleeding or bruising.

LYMPHATICS: Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC: Denies history of depression or anxiety. Pt reports being worried about her
hand since it is the source of her livelihood.

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

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

O.

Physical exam:

Vital Signs:

Temp. 37.0 C, BP 124/78, HR 80, RR 16, SpO2 99% Room Air, Ht 5’4”, Wt 175 lbs.,
BMI 30

General: Obese female, well groomed, A/O x4. Pt is cooperative and presents with no observed
distress.

Cardiovascular: S1 S2 noted. No murmurs, gallops, or rubs noted.

Lungs: Lung sounds clear bilateral. Chest rise and fall symmetrical. No cough noted.

Peripheral Vascular: No edema noted in any extremity. Cap refill less than 3 seconds in all
extremities bilaterally. All extremities are warm and appropriate for ethnicity. Pulses are 2+ in all
extremities.

Neurological: Cranial nerves II – XII are grossly intact. All reflexes are symmetric and 2+.
Finger to nose performed with no abnormalities noted. Romberg and Pronator drift performed.
Sensation diminished to right thumb and index finger. Position of joints: negative; able with no
difference noted between L/R hands. Two-points discrimination, superficial touch: decreased on
R hand only over her thumb, index, and middle fingers. Pain is noted as provider performs
stereognosis and graphesthesia. Pt was able to correctly answer for both tests. Tinel test: positive
for right upper extremity (RUE). Pt reports tingling in right hand only. Phalen’s test: positive
RUE. Pt notes paresthesia and pain in the right hand along median nerve distribution. Sensation
is diminished in the patients right thumb and in her index fingers.

Musculoskeletal: Muscular development and gait are baseline with good posture. Area over
carpal tunnel on right wrist very tender to touch but without crepitation. Back is straight and no
thoracic kyphosis was noted. L arm strength of 5/5 throughout. R arm/hand strength is 3/5.
Weakness noted in hand and thumb abduction R side is 3/5. RLE and LLE strength are both 5/5.
Walks without limp. Roos test was negative.

Diagnostic results:

Lab tests: A1C (possible diabetic neuropathy), thyroid panel,

CBC: WBC 8.6

CMP: Glucose 140

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Hgb A1C 4.5%

C-Reactive Protein: 2.5 mg/L

Further tests needed are X-ray of the wrist and hand.

A .

Differential Diagnoses

1. Thoracic Outlet syndrome
2. Cervical radiculopathy

3. Peripheral Neuropathy

4. Multiple Sclerosis (MS)

5. Stroke

Thoracic outlet syndrome is a complex disease. According to DiLosa and Humphries (2021)
explains the patients symptom of isolated upper extremity pain. The patient does not have any
complaint of neck pain which is a major but does have her arms extended and raised for a great
amount of her day due to her working on client’s hair. According to Dains and colleagues (2019)
this behavior can increase the risk for entrapment.

Cervical radiculopathy is a possibility but unlikely due to the patient not having any neck
pain (Deschenes & Zafereo, 2017). Further examination and the use of an MRI can help to rule
out any nerves being pinched.

Peripheral neuropathy is a definite possibility for this patient. This disease is typically
brought on by diabetes or alcohol abuse (Ball et al., 2019). Due to this reason it is a possible
diagnosis but not probable. However, Anastasi and Pakhomova (2020) discuss how patients with
HIV can have distal sensory peripheral neuropathy. It is critical that providers keep up to date on
current literature in order to keep an open mind about possible differential diagnosis.

MS and Stroke are also possible diagnoses due to the fact that both can present with
numbness and tingling in extremities (Ball et al., 2019). However, due to the fact that numbness
and tingling tend to be minor symptoms for these diseases, they are lower on the list.

P.

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

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References

Anastasi, J. K., & Pakhomova, A. M. (2020). Assessment and Management of HIV Distal

Sensory Peripheral Neuropathy: Understanding the Symptoms. The Journal for Nurse

Practitioners, 16(4), 276–280. https://doi-

org.ezp.waldenulibrary.org/10.1016/j.nurpra.2019.12.019

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to

physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier

Mosby.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical

diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Deschenes, B. K., & Zafereo, J. (2017). Immediate and lasting effects of a thoracic spine

manipulation in a patient with signs of cervical radiculopathy and upper extremity

hyperalgesia: A case report. Physiotherapy Theory & Practice, 33(1), 82–88. https://doi-

org.ezp.waldenulibrary.org/10.1080/09593985.2016.1247307

DiLosa, K. L., & Humphries, M. D. (2021). Epidemiology of thoracic outlet syndrome. Seminars

in Vascular Surgery, 34(1), 65–70. https://doi-

org.ezp.waldenulibrary.org/10.1053/j.semvascsurg.2021.02.008

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Health9

Rubric Detail

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Content

Name: NURS_6512_Week_9_Assignment1_Rubric

  Excellent Good Fair Poor
Using 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.

Points:

Points Range:
45 (45%) – 50 (50%)

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.

Feedback:

Points:

Points Range:
39 (39%) – 44 (44%)

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.

Feedback:

Points:

Points Range:
33 (33%) – 38 (38%)

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.

Feedback:

Points:

Points Range:
0 (0%) – 32 (32%)

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.

Feedback:

·   List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

Points:

Points Range:
30 (30%) – 35 (35%)

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.

Feedback:

Points:

Points Range:
24 (24%) – 29 (29%)

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.

Feedback:

Points:

Points Range:
18 (18%) – 23 (23%)

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.

Feedback:

Points:

Points Range:
0 (0%) – 17 (17%)

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.

Feedback:

Written 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.

Points:

Points Range:
5 (5%) – 5 (5%)

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.

Feedback:

Points:

Points Range:
4 (4%) – 4 (4%)

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.

Feedback:

Points:

Points Range:
3 (3%) – 3 (3%)

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.

Feedback:

Points:

Points Range:
0 (0%) – 2 (2%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time.

No purpose statement, introduction, or conclusion were provided.

Feedback:

Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation

Points:

Points Range:
5 (5%) – 5 (5%)

Uses correct grammar, spelling, and punctuation with no errors.

Feedback:

Points:

Points Range:
4 (4%) – 4 (4%)

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

Feedback:

Points:

Points Range:
3 (3%) – 3 (3%)

Contains several (3 or 4) grammar, spelling, and punctuation errors.

Feedback:

Points:

Points Range:
0 (0%) – 2 (2%)

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

Feedback:

Written 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.

Points:

Points Range:
5 (5%) – 5 (5%)

Uses correct APA format with no errors.

Feedback:

Points:

Points Range:
4 (4%) – 4 (4%)

Contains a few (1 or 2) APA format errors.

Feedback:

Points:

Points Range:
3 (3%) – 3 (3%)

Contains several (3 or 4) APA format errors.

Feedback:

Points:

Points Range:
0 (0%) – 2 (2%)

Contains many (≥ 5) APA format errors.

Feedback:

Show Descriptions

Show Feedback

Using 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.–

Levels of Achievement:

Excellent
45 (45%) – 50 (50%)

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.

Good
39 (39%) – 44 (44%)

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.

Fair
33 (33%) – 38 (38%)

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.

Poor
0 (0%) – 32 (32%)

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.

Feedback:

·   List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.–

Levels of Achievement:

Excellent
30 (30%) – 35 (35%)

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.

Good
24 (24%) – 29 (29%)

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.

Fair
18 (18%) – 23 (23%)

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.

Poor
0 (0%) – 17 (17%)

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.

Feedback:

Written 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.–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

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.

Good
4 (4%) – 4 (4%)

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.

Fair
3 (3%) – 3 (3%)

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.

Poor
0 (0%) – 2 (2%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time.

No purpose statement, introduction, or conclusion were provided.

Feedback:

Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

Uses correct grammar, spelling, and punctuation with no errors.

Good
4 (4%) – 4 (4%)

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

Fair
3 (3%) – 3 (3%)

Contains several (3 or 4) grammar, spelling, and punctuation errors.

Poor
0 (0%) – 2 (2%)

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

Feedback:

Written 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.–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

Uses correct APA format with no errors.

Good
4 (4%) – 4 (4%)

Contains a few (1 or 2) APA format errors.

Fair
3 (3%) – 3 (3%)

Contains several (3 or 4) APA format errors.

Poor
0 (0%) – 2 (2%)

Contains many (≥ 5) APA format errors.

Feedback:

Total Points: 100

Name: NURS_6512_Week_9_Assignment1_Rubric

Health9

1

Week 9 Case Study

Ariana Whetsell, RN

NURS 6512: Advanced Health Assessment

Walden University

Dr. Mary Sizemore

August 1, 2021

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2

Week 9 Case Study

For this assignment, students were asked to review a patient case study related to the
neurological system. Students were then to format a SOAP note for patient. 5 Differential
diagnoses with evidence-based research are to be provided. Lastly, diagnostic testing specific for
this patient will be noted.

SOAP Note

Patient Information:

Name: TG Age: 47-year-old Sex: Female

CC Right wrist numbness and pain

HPI: Patient is a 47-year-old Caucasian female presenting with right wrist pain

Location: Right wrist

Onset: 2 weeks ago

Character: Tingling/ numbness

Associated signs and symptoms: Difficulty grasping tools

Timing: Intermittent

Exacerbating/ relieving factors: Exacerbated by movements of wrist, when styling hair; Relief by
rest

Severity: 7/10 during most painful occurrences

Current Medications: Synthroid 75mcg PO daily; Zoloft 40 mg PO daily

Allergies: Denies medication, food or latex allergies. Denies environmental allergies

PMHx: Hypothyroid; C-section x3; migraine headaches; depression; obesity. Denies other
surgical hx. Flu vaccination (10/2020); Moderna Lot #ID5627 on 7/25/2021 and 6/20/2021

Soc Hx: Patient is hairdresser for last 15 years, working 4 days a week. She lives at home with
husband; Has three children- ages 20,25 and 29- who live away from home. She denies safety or
abuse concerns. Denies tobacco use. Reports drinking one glass of red wine with dinner three
times a week; Denies recreational drug use. Reports good support system with family and church
community.

Fam Hx: Mother- living at 67, diagnosed with hypothyroid and diabetes mellitus type II

Father- living, age 69. hx of gallbladder stones, GERD

Maternal grandmother- living at 88; hx of HTN and hypothyroid

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3

Maternal grandfather- Living at 89; hx of DM II and ESRD

Paternal grandmother- died at 72 from MI

Paternal grandfather- died at 42 from gunshot wound

Children: No medical history or concerns

ROS:

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

HEENT: Denies blurred vision, reports last eye exam was last year- she wears glasses and
contacts; Denies difficulties in swallowing.

CARDIOVASCULAR: Denies chest pain or discomfort. Denies edema. Denies cardiac history;
Last EKG in 2020 at annual visit.

RESPIRATORY: Denies shortness of breath, cough or sputum. Denies history of respiratory
diagnoses.

GASTROINTESTINAL: Denies abdominal pain or cramping. Reports diet has been tolerated.
Last BM reported as this morning.

GENITOURINARY: Denies burning or painful urination

NEUROLOGICAL: Denies dizziness, headaches or numbness to extremities.

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

PSYCHIATRIC: Denies history of depression or anxiety.

O.

Neuro: Alert and oriented, responds appropriately to questions. No discoloration noted to right
hand/ extremity during numbness episode. Cranial nerves- intact.

Cardiac: S1 and S2 audible: No murmurs or gallops noted; Regular heart sounds; No edema
noted to peripheral extremities

Resp: Room air; Clear lung sounds throughout; No cough noted; No sputum production noted

Musculoskeletal: Gait steady, no assistive devices present strength, +5 in all extremities. Some
limited ROM noted to R wrist

Diagnostic results: Nerve conduction study- composed of small, electric shocks, determining
nerve impulses. Other diagnostic testing includes electromyography, which is when fine needles
are inserted into muscles which displays the electrical activity. Imaging testing includes
ultrasounds, MRI and X-rays. Ultrasounds can show medial nerve enlargement. MRIs are able
to rule out other diagnoses. X-rays are able to determine if bone fractures or arthritis are present
(NINDS, 2020). Lab testing includes HgA1C and CBC can be completed to determine presence
of diabetes or infection (NINDS, 2020).

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4

A .

Carpal Tunnel Syndrome- Carpal tunnel syndrome occurs when pressure is present on the
median nerve. Individuals experience numbness and tingling sensations to their fingers (Mayo
Clinic Staff, 2020; NINDS, 2020). The fingers most effected are the index, middle and ring
fingers. This location is where the patient expresses her pain. Weakness, causing individuals to
drop objects is also noted as symptom, and in patient (Mayo Clinic Staff, 2020; NINDS, 2020).
Risk factors for carpal tunnel present in patient includes obesity, thyroid problems, female
gender and her workplace requirements (Mayo Clinic Staff, 2020).

Tendonitis- Tendonitis of wrist, or tenosynovitis, typically affects pain in the thumb side of wrist.
Pain is most notable during grasping items or forming fist with hand. It can be caused be caused
by repetitive movements. The case study patient completes repetitive movements during her
workplace requirements. Other symptoms may include swelling, and a sticking feeling in the
thumb. It is more common in females, ages 30 to 50, which fits the patient profile (Mayo Clinic
Staff, 2020b).

Arthritis- Wrists commonly experience arthritis due to repetitive, everyday movements. Arthritis
is the inflammation of the joint, in this case the wrist. Symptoms may include pain, edema,
stiffness and decreased range of motion. Osteoarthritis would be more likely in this patient case.
A CBC results leukocytes, which allows us to see if infection is present. A synovial fluid analysis
may also be completed to determine infection presence (Akhondi & Panginikkod, 2021).

Peripheral Neuropathy- Peripheral neuropathy can cause motor nerve and sensory nerve damage.
Symptoms include pain, cramping and temperature variations. The patient symptoms are more
likely autonomic nerve damage, in which wrist pain is common. Reasons for peripheral
neuropathy may include physical injury. Nerve conduction velocity tests, electromyography,
nerve biopsies, MRIs and CTs are diagnostic tests for peripheral neuropathy (NINDS, 2018).

Sprained Wrist- Sprained wrists are a common injury caused by work environment. Typically,
repetitive movements in the work environment can result in sprained wrist. Symptoms of wrist
sprains include pain, swelling, bruising and movement difficulties. X-rays, CTs and MRIs can be
completed for diagnostic tests (May & Varacello, 2021).

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5

References

Akhondi, H. & Panginikkod, S. (2021). Wrist arthritis. StatPearls.
https://www.ncbi.nlm.nih.gov/books/NBK531497/

May, D.D. & Varacallo, M. (2021). Wrist sprain. StatPearls.
https://www.ncbi.nlm.nih.gov/books/NBK551514/

Mayo Clinic Staff (2020a). Carpal tunnel syndrome. MayoClinic.
https://mayoclinic.org/diseases-conditions/carpal-tunnel-syndrome/symptoms-
causes/sync-20355607

Mayo Clinic Staff (2020b). DeQuervains tenosynovitis. MayoClinic.
https://mayoclinic.org/diseases-conditions/de-quervains-tenosynovitis/symptoms-
causes/syc-20371332

National Institute of Neurological Disorders and Stroke (2018). Peripheral neuropathy fact
sheet. https://ninds.nih.gov/disorders/patient-caregiver-education/fact-sheets/peripheral-
neuropathy-fact-sheet

National Institute of Neurological Disorder and Stroke (2020). Carpal Tunnel Syndrome Fact
Sheet [Fact Sheet]. https://ninds.nih.gov/disorders/patient-caregiver-education/ fact-
sheets/carpal-tunnel-syndrome-fact-sheet

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Health9


NURS 6512: Advanced Health Assessment and Diagnostic Reasoning


Assignment 1: Case Study Assignment: Assessing Neurological Symptoms

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

· You will be assigned to a specific case study for this Case Study Assignment.

· Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. See attached Episodic/Focused SOAP Template. 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 5 possible conditions that may be considered in a differential diagnosis for the patient.

The Case Study Assignment


Case study:


A 48 year old male with a history of diabetes mellitus type 2 complains of not being able to feel his toes in the left foot. He also complains of numbness in the heel of the right foot and a tingling sensation.

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 5 different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 


Learning Resources

https://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=136466230&site=ehost-live&scope=site&authtype=shib&custid=s6527200

https://go.openathens.net/redirector/waldenu.edu?url=https://www.sciencedirect.com/science/article/pii/S0020748919300446?via%3Dihub

https://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=139036926&site=ehost-live&scope=site&authtype=shib&custid=s6527200