NURS 6512: Advanced Health Assessment and Diagnostic Reasoning:

 

 

 

 

 

 

 

Week 9: Case Study Assignment: Assessing Neurological Symptoms

 

 

 

 

 

 

 

 

Student’s Name

Institution

Course

Lecturer’s Name

Date

 

 

 

 

Week 9 NEURO SOAP Note

 

Patient Initials: T.N              Age: 67 years                        Gender: Male

 

 

SUBJECTIVE DATA:

 

Chief Complaint (CC): “Very Forgetful”

 

History of Present Illness (HPI): N.S is a 67-year-old Asian male who was brought in by his daughter for psychiatric evaluation since he was very forgetful. She reports that the patient has lost his car keys several times. She also reports that sometimes when the patient goes to the store, he forgets his way back and calls for help. The patient claims that he started being forgetful about 2 years back, and it has been getting worse ever since as reported by his daughter. The patient denies any associated symptoms. No hallucination or delirium.

 

Medications:

1. Losartan 50mg PO once daily for the management of his high blood pressure.

 

Allergies:

No known drug, food, or environmental allergies

 

Past Medical History (PMH):

High Blood Pressure

 

Past Surgical History (PSH):

Denies ever undergoing any surgical procedure in the past.

 

Sexual/Reproductive History:

Heterosexual

 

Personal/Social History:

Married with a daughter and a son. His wife however passed on 2 years ago.

Retired but owned and ran his café downtown for several years.

He lives by himself, but the daughter lives next door and checks on him now and then.

Confirms taking one or two beers when with friends.

Denies smoking tobacco or using any other recreational drug.

 

Health Maintenance:

The patient used to exercise before by walking the dog, but ever since he started being forgetful, he does not remember the last time he went for a long walk. He however consumes a healthy diet which his daughter makes sure of. He uses a seat belt when in the care and lives in a well-maintained house. Confirms sleeping for about 8 hours every night.

 

Immunization History:

Flu shot 16/1/2022

Covid Vaccine #1 4/1/2021 #2 2/1/2021 Moderna

All other immunization up to date

Significant Family History:

The patient’s mother passed on at the age of 86 years due to cardiac arrest, upon receiving a report that her grandson had been involved in a car accident. His father is alive at the age of 94 years with a history of diabetes, dementia, arthritis, and thyroid disorder. Both his children are healthy with no significant history of any chronic medical condition.

 

Review of Systems:

General: Appears healthy with no signs of distress. No signs of fatigue, chills, fever, or generalized body weakness.

 

HEENT: Head: No signs of trauma or headache reported. Eyes: Denies blurred vision, use of corrective lenses, excessive tearing, or redness. Ears: No tinnitus, itchiness, or hearing loss. Nose: no congestion, running nose, sinus problems, or nose bleeding. Throat & Mouth: No sore throat, coughing, swallowing difficulties, or dental problems. Neck: No tenderness, signs of injury, enlarged tonsils, or a history of disc disease or compression.

 

Respiratory: No wheezing, coughing, shortness of breath, or breathing difficulties.

 

CV: Denies chest pain, edema, orthopnea, syncope, or palpitations. Dyspnea on exertion

 

GI: No abdominal tenderness, constipation, diarrhea, distention, changes in bowel movement, or jaundice.

 

GU: Denies incontinence, urinary frequency, hematuria, dysuria, or burning sensation when urinating.

 

MS: Denies back pain, with a full range of movement in all the extremities. No signs of spinal code injury.

 

Psych: Denies paranoia, hallucinations, delirium, suicidal ideation, mental disturbance, memory loss, anxiety or depression, or a history of psychosis.

 

Neuro: Denies vertigo, tremors, syncope, seizures, paresthesia, or transient paralysis.

 

Integument/Heme/Lymph: No bruising, ecchymosed, ulcers, lesions, or rashes. No signs of enlarged lymph nodes.

 

Endocrine: Denies heat intolerance, cold intolerance, polyuria, polyphagia, or polydipsia.

 

Allergic/Immunologic: Denies hay fever, urticaria, or persistent infections.

 

OBJECTIVE DATA:

 

Physical Exam:

 

Vital signs: T: 97.7°F (36.5°C), BP: 125/70 mm Hg, HR 70/min, R: 18/min, memory loss 8/10. Ht. 5’9’’, Wt. 179 pounds, BMI: 23.5

 

General: N.S appears healthy and well cooperative through the examination with a pleasant mood. He experiences no chills, fever, fatigue, or recent changes in body weight.

 

Chest/Lungs: Lungs are clear to auscultation and percussion bilaterally. No rhonchi or wheezing.

 

Heart/Peripheral Vascular: S1 and S2 present. No rubs, gallops, or murmurs. Regular rate and rhythm

 

Lymphatics: No signs of enlarged lymph nodes.

                       

Neurological: The CN II-VII and the DTR are undamaged. Denies headache, syncope, or dizziness. Confirms worsening memory loss for the past 2 years

 

Psychiatric: Denies feeling hopeless, or having suicidal ideations. Confirms being in mild distress due to memory loss leading to cognitive impairment.

 

Diagnostic results:

TSH – To determine if the patient memory loss is associated with hypothyroidism.

MRI of the head – To assess whether there is any form of damage to the neurotransmitters or the presence of any form of brain cell tumor.

Cerebral angiography – To measure the blood flow through the brain for any signs of deficiencies.

Amyloid imaging –

Cognitive test – To determine whether the patient’s memory loss is associated with anxiety or distress (Bruno, 2020).

 

ASSESSMENT:

 

1. Alzheimer’s disease: Alzheimer’s disease is a progressive neurologic disorder that leads to atrophy of the brain and death of brain cells (Glymour et al., 2018). This disorder is the most common form of dementia among the elderly above the age of 65 years. It is characterized by significant cognitive deterioration which undermines the patient’s ability to sustain independent living. The diagnosis of this disorder is based on three stages, with the first stage regarded as the preclinical stage with no symptoms. The second stage which is referred to as the middle stage is characterized by mild cognitive impairment, whereas the final stage is characterized by marked symptoms of dementia. The patient in the provided case study presents with worsening memory loss, for the past two years, which indicates the final stage of Alzheimer’s as the primary diagnosis.
2. Vascular cognitive impairment (VCI): This is a disorder of the mind with undermines the patient’s mental ability to think, feel and be awake (Ghafar et al., 2019). VCI presents with cognitive symptoms ranging from being forgetful in mild cases. However, in severe cases, patients may present with serious cognitive impairments leading to problems with memory, attention, language, and executive functions such as problem-solving. The patient in the provided case study reports being forgetful, However, cognitive testing is required to confirm this diagnosis.
3. Vascular dementia: This refers to a decline in the patients thinking skills due to conditions that reduce or block the flow of blood to various parts of the brain, depriving them of nutrients and oxygen (Bruno, 2020). Patients will present with symptoms such as forgetfulness, poor balance, confusion, and disorientation among others. The patient in the provided case study however presented with forgetfulness only, with no associated symptoms.
4. Idiopathic normal pressure hydrocephalus (INPH): This is a disorder of the brain characterized by impairment of the patient’s gait, urinary incontinence, and decline in cognitive function. It is normally associated with ventriculomegaly in the absence of increased cerebrospinal fluid (CSF) pressure (Kockum et al., 2020). Forgetfulness and confusion are one of the most common early symptoms, among others such as depression, trouble walking, poor balance, and falling. Neuroimaging with either CT or MRI is however required to confirm this diagnosis to assess for hydrocephalus pressure.
5. Lewy body dementia (LBD): It is a rare disease associated with abnormal deposition of alpha-synuclein in the brain. These deposits, known as Lewy bodies lead to a progressive decline in the patient’s cognitive ability (Gan et al., 2021). Patients will present with common signs and symptoms such as memory loss, tremors, slow movement, muscle rigidity, loss of coordination, and reduced facial expression. However, the diagnosis of this disorder requires the patient to present with declining thinking ability in addition to at least two of the following symptoms, parkinsonian symptoms, repeated visual hallucinations, and fluctuating alertness.

 

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

 

 

References

Bruno, A. (2020). Forgetfulness. The Family Nurse Practitioner: Clinical Case Studies, 245-249.

Gan, J., Liu, S., Wang, X., Shi, Z., Shen, L., Li, X., … & Ji, Y. (2021). Clinical characteristics of Lewy body dementia in Chinese memory clinics. BMC neurology, 21(1), 1-11. https://doi.org/10.1186/s12883-021-02169-w

Ghafar, M. Z. A. A., Miptah, H. N., & O’Caoimh, R. (2019). Cognitive screening instruments to identify vascular cognitive impairment: A systematic review. International Journal of Geriatric Psychiatry, 34(8), 1114-1127.

Glymour, M. M., Brickman, A. M., Kivimaki, M., Mayeda, E. R., Chêne, G., Dufouil, C., & Manly, J. J. (2018). Will biomarker-based diagnosis of Alzheimer’s disease maximize scientific progress? Evaluating proposed diagnostic criteria. European Journal of Epidemiology, 33(7), 607-612. https://doi.org/10.1007/s10654-018-0418-4

Kockum, K., Virhammar, J., Riklund, K., Söderström, L., Larsson, E. M., & Laurell, K. (2020). Diagnostic accuracy of the iNPH Radscale in idiopathic normal pressure hydrocephalus. PLoS One, 15(4), e0232275.