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Welcome to Week 9. This week we will review the “Assessment of Cognition and the Neurologic System”. You have a case study due this week on Assessing Neurologic Symptoms. I have assigned the case studies below. You will see the corresponding case study number next to your name. For this assignment you will create a focused/episodic note on your assigned case study. You will create all the missing information that is needed to develop the SOAP note. Then provide at least 5 differential diagnoses with rationales for each diagnosis.
You also have your final DCE which is a Head-to-Toe Comprehensive Physical Exam due this week. As per the syllabus and rubric, you must pass this assignment with a combined score of 80 or better (lab pass & documentation template) to pass the course. So please do not leave a section unanswered. Remember the physical exam goes under the objective section and the diagnoses are under the assessment section. If you are confused, please reach out to me. Please thoroughly document this comprehensive visit. If you attempt to use the SOAP format, be sure to include everything in each section. But I advise you to use the template provided to make sure you do not miss a section.
Please do not add any mnemonics, bullet points or write your entire note in bold. Points will be taken off if you continue to do this. Also do not write within normal limits in your physical exam or review of systems. You should write out the symptoms (ROS) or exam findings (Physical Exam).
We are nearing the end of the course. I am looking forward to everyone finishing strong. If you have any questions, please feel free to send me an email. If you have any missing assignments from week 7 or 8, please complete them now.
Have a great week!
Case Studies
Case Study 1: Facial Droop
22 year old african american female looks in the mirror and notices the left side of her mouth is slanted when she smiles. She notes she has had some headache off and on a few days. Her taste has decreased as well when she started brushing her teeth. 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.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources. WEEKLY RESOURCES
TO PREPARE
By 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.
With regard to the case study you were assigned:
Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study you were assigned.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
THE CASE STUDY ASSIGNMENT
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. BY DAY 6 OF WEEK 9
Submit your Assignment. SUBMISSION INFORMATION
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area. To submit your completed assignment, save your Assignment as WK9Assgn1+last name+first initial.
Then, click on Start Assignment near the top of the page.
Next, click on Upload File and select Submit Assignment for review.
Rubric
NURS_6512_Week_9_Assignment1_Rubric
NURS_6512_Week_9_Assignment1_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeUsing 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.
50 to >44.0 pts
Excellent
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.
44 to >38.0 pts
Good
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.
38 to >32.0 pts
Fair
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.
32 to >0 pts
Poor
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.
50 pts
This criterion is linked to a Learning Outcome· List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
35 to >29.0 pts
Excellent
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.
29 to >23.0 pts
Good
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.
23 to >17.0 pts
Fair
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.
17 to >0 pts
Poor
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.
35 pts
This criterion is linked to a Learning OutcomeWritten 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 to >4.0 pts
Excellent
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 to >3.0 pts
Good
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 to >2.0 pts
Fair
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.
2 to >0 pts
Poor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided. 5 pts This criterion is linked to a Learning OutcomeWritten Expression and Formatting - English writing standards: Correct grammar, mechanics, and proper punctuation 5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.
4 to >3.0 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
3 to >2.0 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.
2 to >0 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts
This criterion is linked to a Learning OutcomeWritten 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 to >4.0 pts
Excellent
Uses correct APA format with no errors.
4 to >3.0 pts
Good
Contains a few (1 or 2) APA format errors.
3 to >2.0 pts
Fair
Contains several (3 or 4) APA format errors.
2 to >0 pts
Poor
Contains many (≥ 5) APA format errors.
5 pts
Total Points: 100
NB
MUST HAVE AT LEAST 3 REFERENCES IN APA
DO NOT TAKE UP THIS PAPER IF YOU ARE NOT KNOWLEDGEABLE IN MEDICINE OR ADVANCED HEALTH ASSESSMENTS