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NURS 6512 Week 9 Assignment: Assessing Neurological Symptoms

NURS 6512 Week 9 Assignment: Assessing Neurological Symptoms NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsAssignment 1: Case Study Assignment: Assessing Neurological SymptomsImagine 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 PrepareAlso,      your Case Study Assignment should be in the Episodic/Focused SOAP Note      format rather than the traditional narrative style format.With regard to the case study you were assigned:NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsReview      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 assessment and diagnostic assessment 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.ORDER A PLAGIARISM-FREE PAPER HEREThe Case Study AssignmentUse 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 assessment 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 study22 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.NURS 6512 Week 9 Assignment: Assessing Neurological Symptomscomplete the assignment using the attached templateEpisodic/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:NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsLocation: 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).NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsPMHx: 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.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsExample of Complete ROS:GENERAL:  No weight loss, fever, chills, weakness or fatigue.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.SKIN:  No rash or itching.CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.RESPIRATORY:  No shortness of breath, cough or sputum.GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.HEMATOLOGIC:  No anemia, bleeding or bruising.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsLYMPHATICS:  No enlarged nodes. No history of splenectomy.PSYCHIATRIC:  No history of depression or anxiety.ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.ALLERGIES:  No 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.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 6th edition formatting.A 63-year-old woman comes to your office because she’s been forgetting things…a young mother comes in concerned because her baby fails to make eye contact and is unresponsive to touch…a teenager comes in and a parent complains that the teen obsessively washes his hands.An array of neurological conditions could be causing the above symptoms. When assessing the neurologic system, it is vital to formulate an accurate diagnosis as early as possible to prevent continued damage and deterioration of a patient’s quality of life.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsThis week, you will explore methods for assessing the cognition and the neurologic system.Learning ObjectivesStudents will:Evaluate abnormal neurological symptomsApply concepts, theories, and principles relating to health assessment techniques and diagnoses for cognition and the neurologic systemAssess health conditions based on a head-to-toe physical examinationLearning ResourcesRequired Readings (click to expand/reduce) 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. Chapter 7, “Mental Status”This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms.NURS 6512 Week 9 Assignment: Assessing Neurological Symptoms·Chapter 23, “Neurologic System”The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings.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.Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.Chapter 4, “Affective Changes”This chapter outlines how to identify the potential cause of affective changes in a patient. The authors provide a suggested approach to the evaluation of this type of change, and they include specific tools that can be used as part of the diagnosis.Chapter 9, “Confusion in Older Adults”This chapter focuses on causes of confusion in older adults, with an emphasis on dementia. The authors include suggested questions for taking a focused history as well as what to look for in a physical examination.Chapter 13, “Dizziness”Dizziness can be a symptom of many underlying conditions. This chapter outlines the questions to ask a patient in taking a focused history and different tests to use in a physical examination.Chapter 19, “Headache”The focus of this chapter is the identification of the causes of headaches. The first step is to ensure that the headache is not a life-threatening condition. The authors give suggestions for taking a thorough history and performing a physical exam.Chapter 31, “Sleep Problems”In this chapter, the authors highlight the main causes of sleep problems. They also provide possible questions to use in taking the patient’s history, things to look for when performing a physical exam, and possible laboratory and diagnostic studies that might be useful in making the diagnosis.Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5)Note: Download the Physical Examination Objective Data Checklist to use as you complete the Comprehensive (Head-to-Toe) Physical Assessment assignment.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsSeidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical examination objective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance Center.Note: Download and review the Student Checklists and Key Points to use during your practice neurological examination.Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Mental status: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.Bearden , S. T., & Nay, L. B. (2011). Utility of EEG in differential diagnosis of adults with unexplained acute alteration of mental status. American Journal of Electroneurodiagnostic Technology, 51(2), 92–104.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsThis article reviews the use of electrocenographs (EEG) to assist in differential diagnoses. The authors provide differential diagnostic scenarios in which the EEG was useful.Athilingam, P ., Visovsky, C., & Elliott, A. F. (2015). Cognitive screening in persons with chronic diseases in primary care: Challenges and recommendations for practice. American Journal of Alzheimer’s Disease & Other Dementias, 30(6), 547–558. doi:10.1177/1533317515577127Sinclair , A. J., Gadsby, R., Hillson, R., Forbes, A., & Bayer, A. J. (2013). Brief report: Use of the Mini-Cog as a screening tool for cognitive impairment in diabetes in primary care. Diabetes Research and Clinical Practice, 100(1), e23–e25. doi:10.1016/j.diabres.2013.01.001Roalf, D. R., Moberg, P. J., Xei, S. X., Wolk, D. A., Moelter, S. T., & Arnold, S. E. (2013). Comparative accuracies of two common screening instruments for classification of Alzheimer’s disease, mild cognitive impairment, and healthy aging. Alzheimer’s & Dementia, 9(5), 529–537. doi:10.1016/j.jalz.2012.10.001. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036230/Shadow Health Support and Orientation ResourcesUse the following resources to guide you through your Shadow Health orientation as well as other support resources:Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkYShadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-usDocument: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)Document: Student Acknowledgement Form (Word document)Note: You will sign and date this form each time you complete your DCE Assignment in Shadow Health to acknowledge your commitment to Walden University’s Code of Conduct.Document: DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment (Word document)NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsUse this template to complete your Assignment 3 for this week.Optional ResourcesLeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical. Chapter 14, “The Neurologic Examination” (pp. 683–765)This chapter provides an overview of the nervous system. The authors also explain the basics of neurological exams. Chapter 15, “Mental Status, Psychiatric, and Social Evaluations” (pp. 766–786)In this chapter, the authors provide a list of common psychiatric syndromes. The authors also explain the mental, psychiatric, and social evaluation process.Mahlknecht, P., Hotter, A., Hussl, A., Esterhammer, R., Schockey, M., & Seppi, K. (2010). Significance of MRI in diagnosis and differential diagnosis of Parkinson’s disease. Neurodegenerative Diseases, 7(5), 300–318.Required Media (click to expand/reduce)NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsAssignment 1: Case Study Assignment: Assessing Neurological SymptomsPhoto Credit: Getty Images/iStockphotoImagine 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 fromsevere 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 PrepareBy 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.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsWith 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 AssignmentUse 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.By Day 6 of Week 9Submit your Assignment.Submission and Grading InformationTo submit your completed Assignment for review and grading, do the following:Please save your Assignment using the naming convention “WK9Assgn1+last name+first initial.(extension)” as the name.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsClick the Week 9 Assignment 1 Rubric to review the Grading Criteria for the Assignment.Click the Week 9 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK9Assgn1+last name+first initial.(extension)” and click Open.If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.Click on the Submit button to complete your submission.Grading CriteriaTo access your rubric:Week 9 Assignment 1 RubricCheck Your Assignment Draft for AuthenticityTo check your Assignment draft for authenticity:Submit your Week 9 Assignment 1 draft and review the originality report.Submit Your Assignment by Day 6 of Week 9To participate in this Assignment:Week 9 Assignment 1NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsAssignment 2: Lab Assignment (Optional): Practice Assessment: Neurological ExaminationShort of opening a patient’s cranium or requesting a brain scan, what can an advanced practice nurse do to determine the cause of neurological symptoms? A multitude of techniques can be used to generate a neurological diagnosis.In preparation for the Comprehensive (Head-to-Toe) Physical Assessment due this week, it is recommended that you practice performing a neurological examination.Note: This is an optional practice physical assessment.To PrepareArrange an appropriate time and setting with a volunteer “patient” to perform a neurological examination.Download and review the Neurological Checklist provided in this week’s Learning Resources as well as review Seidel’s Guide to Physical Examination online media.The Lab AssignmentPerform the neurological examination. Be sure to cover all of the areas listed in the checklist and to use the plexor appropriately.Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical AssessmentThroughout this course, you were encouraged to practice conducting various physical assessments on multiple areas of the body, ranging from the head to the toes. Each of these assessments, however, was conducted independently of one another. For this DCE Assignment, you connect the knowledge and skills you gained from each individual assessment to perform a comprehensive head-to-toe physical examination in your Digital Clinical Experience.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsPhoto Credit: Getty Images/Hero ImagesTo PrepareReview this week’s Learning Resources, and download and review the Physical Examination Objective Data Checklist as well as the Student Checklists and Key Points documents related to neurologic system and mental status.Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.Review the DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.Review the Week 9 DCE Comprehensive Physical Assessment Rubric provided in the Assignment submission area for details on completing the Assessment in Shadow Health.Note: There are 2 parts to this assignment – the lab pass and the documentation. You must achieve a total score of 80% in order to pass this assignment. Carefully review the rubric and video presentation in order to fully understand the requirements of this assignment.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsDCE Comprehensive Physical Assessment:Complete the following in Shadow Health:Episodic/Focused Note for Comprehensive Physical Assessment of Tina Jones (180 minutes)Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 9 Day 7 deadline.Submission and Grading InformationBy Day 7 of Week 9Complete your Comprehensive (Head-to-Toe) Physical Assessment DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding Assignment in Blackboard for your faculty review.(Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-passOnce you submit your Documentation Notes to Shadow Health, make sure to copy and paste the same Documentation Notes into your Assignment submission link below.Download, sign, date, and submit your Student Acknowledgement Form found in the Learning Resources for this week.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsNote: You must pass this assignment with a minimum score of 80%  in order to pass the class. Once submitted, there are not any opportunities to revise or repeat this assignment. Grading CriteriaTo access your rubric:Week 9 Assignment 3 DCE RubricSubmit Your Assignment by Day 7 of Week 9To submit your Lab Pass:Week 9 Lab PassTo sumit this required part of the Assignment:Week 9 Documentation Notes for Assignment 3To Submit your Student Acknowledgement Form:Submit your Week 9 Assignment 3 DCE Student Acknowledgement FormCase 1: HeadachePatient Information:Initials: P.K                 Age: 20 years old        Sex: Male        Race: AsianS.CC (chief complaint): “Headache”HPI: P.K is a 20 years old Asian male patient who presented to the clinic complaining of intermittent headaches. He claims that the headache diffuses all over the head. However, the patient claims that the pressure and intensity are mainly located on the forehead above the eyes, the jaw, cheekbones, and the nose.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsLocation: headOnset: The patient claims that the headache started 3 days before the present visit.Character: He describes the pain as dull and pounding.Associated signs and symptoms: photophobia, phonophobia, and nauseaTiming: IntermittentExacerbating/ relieving factors: Placing a cool rag on the forehead alleviates the pain, while it is worsened by noise.Severity: 7/10 on a pain scaleCurrent Medications: Flonase nasal spray, which he administers 2 sprays per nostril only once a day to manage the symptoms resulting from seasonal allergies. Over-the-counter Tylenol 1g orally after every six hours, PRN for management of the headache.Allergies: None.PMHx: Underwent appendectomy at an early age, when he was 10 years old. In 2008, the patient underwent spinal fusion surgery L4-L5, and cervical spinal fusion T2-T3 in 2010, as a result of degenerative disk disease.Vaccination: Last tetanus vaccine in 2010. The patient’s last flu shot was administered in October 2020. Confirms that all the childhood development immunization is up to date.Soc Hx: The patient is an accountant and takes part in competitive throwing of darts. He is currently single, and heterosexual but with no sexual partner at the moment. He denies having any plan to date soon. He denies smoking or being a passive smoker. He does not take alcohol. Safety characters are exhibited as he uses a seat belt when driving and reports that there are no guns at his place. He confirms taking coffee up to 3 cups a day. In addition to soda and caffeinated beverages.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsFam Hx: Father is still alive at the age of 81 years, managing skin cancer, HTN, and coronary artery disease. Mother passed on at the age of 71 years from breast cancer. All the grandparents passed on with no known health complications. The patent has only one sibling who is struggling with CVA at the age of 55.ROS:GENERAL: No recent changes in body weight, appetite, fever, chills, fatigue, nausea, or vomiting.HEENT: Head: No signs of trauma, with equal hair distribution. Eyes: No changes in visual acuity, yellow sclera, or a history of using visual aid. Confirms increased eye sensitivity to light when experiencing headaches. Ears: No discharge, pain, tinnitus, hearing problems, or itchiness. Nose: Reports painful sinuses during headaches, and seasonal rhinitis. Throat: No sore throat, difficulties in swallowing, or enlarged thyroid.SKIN: Smooth and warm, with no signs of infections or pruritus.CARDIOVASCULAR: Denies chest problems, pressure, pain, or heart racing.RESPIRATORY: Denies congestions, coughing, dyspnea, or wheezingGASTROINTESTINAL: No signs of abdominal distension, pain on palpation, or mass.GENITOURINARY: No changes in urine frequency, polyuria, or burning sensation when urinating.NEUROLOGICAL: Reports intermittent headaches. No signs of seizures, dizziness, or changes in bladder or bowel movement.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsMUSCULOSKELETAL: Denies stiffness of joints or muscle fatigue and pain.HEMATOLOGIC: No history of blood disorders.LYMPHATICS: Denies enlargement of lymph nodes.PSYCHIATRIC: Denies any current psychiatric symptoms. Reports a history of anxiety and depression which is resolved.ENDOCRINOLOGIC: Denies heat or cold intolerance, polydipsia, or polyuria.ALLERGIES: Reports latex and seasonal allergies. Denies any other allergic condition.O.Physical exam:Vitals: BP 110/85; P 76; T 98.6; R 17 PsaO2 98% room air.GENERAL: Appears well-nourished with age-appropriate clothing. Reports intermittent headache, photophobia, phonophobia, sound intolerance, and occasional nausea and vomiting as a result of the headache.HEENT: Head: Atraumatic with equal distribution of hair. Eyes: No signs of inflammation, redness, or itchiness. Clear sclera. Equal pupil reaction to light bilaterally. Ears: PEARL tympanic membrane. No signs of erythema. Nose: patent naris, intact septum, and mild clear rhinorrhea seen. No signs of ulceration or inflammation of the gums. Throat: No signs of swollen tonsils.NECK: Symmetric with the aligned trachea. Palpable thyroid gland with no signs of abnormalities.CARDIOVASCULAR: S1 and S2 noted. No irregular or abnormal sounds. Regular heart rate and rhythm.RESPIRATORY: Clear lung sounds. No rales or abnormal sounds were noted.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsNEUROLOGICAL: Responds appropriately to questions. Well oriented in person, place, and time. bilaterally equal pupil with a similar light response. Displays equal handgrip strength. Long-term and short-term memories are intact (Balgetir et al., 2019). On a pain scale from 0 to 10 with 0 being mild and 10 severe, the patient rates the pain 7/10.  The headache is also associated with photophobia, nausea, and vomiting.Diagnostic results: Routine lab tests such as CBC and white blood cell count ordered to check for signs of infection. Sinus Aspiration was performed to confirm bacterial sinusitis. Nasal smear and nasal scarping do evaluate the presence of allergic rhinitis. An allergic skin test was also performed to assess the reasons behind the seasonal allergy (Itanyi et al., 2020). Nasal endoscopy, CT scan, and MRI to assess the severity of the patient’s condition, by observing the brain tissue anatomy and the soft tissue pathology.A.Differential DiagnosesAcute Sinusitis: This is a short-term inflammatory condition of the sinuses lasting for less than 4 weeks. It is most common among individuals with seasonal allergies. Patients diagnosed with this disorder normally present with facial pain, tenderness and pressure, stuffy nose, thick yellow-greenish discharge, nasal congestion, headache, fever, and ear pain (Kirsch, 2019). The patient in the provided case scenario presented most of these symptoms with the chief complaint of sinus headache, presenting as pressure around the forehead, cheeks, and eyes. This disorder meets the patient’s diagnostic threshold from the provided history and examination results.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsMigraine without aura: This disorder is characterized by paroxysmal pain episodes which last for about 4 to 72 hours and are associated with symptoms such as photophobia, phonophobia, nausea, and vomiting (Diener et al., 2020). The patient in the provided case study displayed all the above four symptoms. This disorder is also diagnosed when the cause of the patient’s headaches is not associated with another disorder. The patient, however, displays several symptoms which show that the pain might be a result of other causes.Medication rebound headache: medication overuse headache or rebound headaches normally result from long-term use of pain medication for conditions such as migraines. Common signs and symptoms include nausea, memory loss, irritability, restlessness, and intermittent headaches (Chinthapalli et al., 2018). The patient in the provided case study complains of intermittent headache and nausea. Consequently, he has been on pain medications for an extended period, as a result of the three surgeries which he went through.Allergic Rhinitis: Commonly referred to as hey fever is an immune disorder caused by seasonal or perennial allergies. The disease is characterized by sneezing, running nose, sneezing, fatigue, itchy eyes, and frequent headaches (Ceriani, & Silberstein, 2021). The patient in the provided case study has seasonal allergies with a history of allergic rhinitis. He also presents with intermittent headache which makes allergic rhinitis a differential diagnosis.Rhinitis medicamentosa: This is a non-allergic type of rhinitis which results from prolonged use of nasal decongestants topically. In this case, prolonged use means more than 5 straight days (Smith et al., 2019). Patients will present with sneezing, postnasal drip, or nasal congestion without rhinorrhea. Some patients might display intermittent headaches with compliance to pressure just like the patient in the provided case study.NURS 6512 Week 9 Assignment: Assessing Neurological Symptoms Rubric DetailSelect Grid View or List View to change the rubric’s layout.Name: NURS_6512_Week_9_Assignment1_RubricGrid ViewList ViewExcellent Good Fair PoorUsing 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.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.39 (39%) – 44 (44%)NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsThe 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.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.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.· List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.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.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.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.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.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.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.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.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.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.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsWritten Expression and Formatting – English writing standards:Correct grammar, mechanics, and proper punctuation5 (5%) – 5 (5%)Uses correct grammar, spelling, and punctuation with no errors.4 (4%) – 4 (4%)Contains a few (1 or 2) grammar, spelling, and punctuation errors.3 (3%) – 3 (3%)Contains several (3 or 4) grammar, spelling, and punctuation errors.0 (0%) – 2 (2%)Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.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.5 (5%) – 5 (5%)Uses correct APA format with no errors.4 (4%) – 4 (4%)Contains a few (1 or 2) APA format errors.3 (3%) – 3 (3%)Contains several (3 or 4) APA format errors.0 (0%) – 2 (2%)Contains many (≥ 5) APA format errors.Total Points: 100Name: NURS_6512_Week_9_Assignment1_RubricName: NURS_6512_Week_9_Assignment1_RubricGrid ViewList ViewExcellentGoodFairPoorUsing 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 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.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsPoints 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.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.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsPoints 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.·   List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.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.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsPoints 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.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.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.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsWritten 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 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.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsPoints 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.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.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsPoints 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.Written Expression and Formatting – English writing standards:Correct grammar, mechanics, and proper punctuationPoints Range: 5 (5%) – 5 (5%)Uses correct grammar, spelling, and punctuation with no errors.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsPoints Range: 4 (4%) – 4 (4%)Contains a few (1 or 2) grammar, spelling, and punctuation errors.Points Range: 3 (3%) – 3 (3%)Contains several (3 or 4) grammar, spelling, and punctuation errors.Points Range: 0 (0%) – 2 (2%)Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.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 Range: 5 (5%) – 5 (5%)Uses correct APA format with no errors.Points Range: 4 (4%) – 4 (4%)Contains a few (1 or 2) APA format errors.NURS 6512 Week 9 Assignment: Assessing Neurological SymptomsPoints Range: 3 (3%) – 3 (3%)Contains several (3 or 4) APA format errors.Points Range: 0 (0%) – 2 (2%)Contains many (≥ 5) APA format errors. Total Points: 100NURS 6512 Week 9 Assignment: Assessing Neurological Symptoms

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