01 Nov This is a discussion Soap Note. Case 3. My first i
This is a discussion Soap Note. Case 3. My first impression is Bell’s palsy. However, we have to have 5 differential diagnosis. I will attempt to find an example Discussion: 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 Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting. Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the Episodic/Focused SOAP Note format, rather than the traditional narrative style Discussion posting 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. Case 1: Headaches A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw. Case 2: Numbness and Pain A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools. Case 3: Drooping of Face A 33-year-old female comes to your clinic alarmed about sudden “drooping” on the right side of the face that began this morning. She complains of excessive tearing and drooling on her right side as well. To prepare: 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. Note: Before you submit your initial post, replace the subject line (“Discussion – Week 9”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned. By Day 3 Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in 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. Rubric Detail Select Grid View or List View to change the rubric’s layout. Name: NURS_6512_Week_9_Discussion_Rubric • Grid View • List View Outstanding Performance Excellent Performance Competent Performance Proficient Performance Room for Improvement Main Posting: Response to the discussion question is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources. 44 (44%) – 44 (44%) Thoroughly responds to the discussion question(s) is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources. supported by at least 3 current, credible sources 40 (40%) – 43 (43%) Responds to the discussion question(s) is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module. 75% of post has exceptional depth and breadth supported by at least 3 credible references 35 (35%) – 39 (39%) Responds to most of the discussion question(s) is somewhat reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module. 50% of post has exceptional depth and breadth supported by at least 3 credible references 31 (31%) – 34 (34%) Responds to some of the discussion question(s)
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