Case Study: Numbness and Pain
Question
Hello students welcome to Week 9 this week, you will explore methods for assessing the cognition and the neurologic system.
Learning Objectives
Students will:
Evaluate abnormal neurological symptoms
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for cognition and the neurologic system
Assess health conditions based on a head-to-toe physical examination.
During Week 8 you explored how to assess the musculoskeletal system. At this point you should be able to identify abnormal musculoskeletal findings, apply concepts, theories, and principles related to health assessment techniques and diagnoses for the musculoskeletal system and evaluate the musculoskeletal x-ray imaging.
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.
Week 1 Assignment- Case Study- Assessing Neurological Symptoms
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. You will be making up the information that is missing to complete this soap note.
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.
CASE STUDY 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.
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.--
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.
· List five different possible conditions for the patient's differential diagnosis, and justify why you selected each.--
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.
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.--
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.
Written Expression and Formatting - English writing standards:
Correct grammar, mechanics, and proper punctuation--
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.
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.--
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.
Total Points: 100
Name: NURS_6512_Week_9_Assignment1_Rubric
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Solution
Week 9
Shadow Health Comprehensive SOAP Note Template
Patient Initials: M. D Age: __47yrs_____ Gender: _Female______
SUBJECTIVE DATA:
Chief Complaint (CC): Patient presents with pain on her right wrist, tingling and numbness in the thumb, index and middle finger for two weeks.
History of Present Illness (HPI): Patient complains of tingling and numbness on her middle, index and thumb fingers, which was associated with pain causing her to drop her hair-styling tools. For this patient, it would be relevant to obtain the character of the pain at the wrist, the onset and the severity. Exacerbating and alleviating factors also play a great role in finding the right diagnosis. Radiation of the pain to any other body part is important to identify any other cause of the numbness.
Medications: History of drugs like anastrozole, diphosphonates, oral anticoagulants or any antiviral as they predispose one to a condition with such symptoms.
Allergies: No known drug and food allergies
Past Medical History (PMH): History of diabetes, obesity, rheumatoid arthritis fluid retention or thyroid dysfunction. These conditions are mostly linked with a condition with such symptoms.
Past Surgical History (PSH): History of any surgical procedure, blood transfusion or organ transplant.
Sexual/Reproductive History: Age of menopause as it affects as it causes deprivation of certain hormones needed by the bones causing weakness and loss of function. Pregnancy history.
Personal/Social History: Patient occupation as certain occupations like pianists, drivers, typing and agricultural people may present with these symptoms due to repetitive motions of the wrist.
Health Maintenance: Diet and sleep patterns as this a patient is obese hence the diet may be the problem.
Immunization History: History of dates, number of immunizations taken, and if the stipulated schedule is completed. Identify the missed doses responsible for musculoskeletal conditions to rule out conditions like polio.
Significant Family History: Family history of rheumatoid arthritis, diabetes, obesity and carpal tunnel syndrome.
Review of Systems:
General: Patient denies headache, dizziness, exhaustion, fainting and loss of consciousness.
HEENT: Inquire about any head, eye, ears, neck and tongue symptoms.
Respiratory: No positive symptoms
Cardiovascular/Peripheral Vascular: No positive symptoms
Gastrointestinal: No abdominal pain, no diarrhea, vomiting, and positive symptoms.
Genitourinary: No urinary incontinence, no painful urination, no positive symptoms
Musculoskeletal: Pain, numbness and tingling sensation on the wrist and thumb, middle and index fingers. Loss of function on the right wrist.
Neurological: Loss of function of the wrist and pain on the wrist.
Psychiatric: No depressive symptoms, no mania, no posture symptom.
Skin/hair/nails: No rashes, no hyperpigmentation, no lumps, no nodules, no hair loss and no nail symptoms.
OBJECTIVE DATA:
Physical Exam: The patient is in fair general body condition, alert and oriented to time, place and person
Vital signs: Normal vital signs
General: No pallor, no jaundice, no lymphadenopathy, no cyanosis and no finger clubbing.
HEENT: No positive sign
Neck: No swelling, no pain, no tenderness
Chest/Lungs: Lung is clear, airway patent, no tenderness and no positive sign
Heart/Peripheral Vascular: S1 and s2 heard, normal heart rhythm, no positive sign
Abdomen: No tenderness, no masses, no organomegaly and no rebound tenderness.
Genital/Rectal: No positive sign
Musculoskeletal: Phalen's sign test positive, reposition, and opposition test show less muscle strengths, the okay sign and use of a reflex hammer to tap on the median nerve of the wrists to see if fingers tingle or feel any sensation (Sevy & Varacallo 2020).
Neurological: Loss of sensation on the wrist. According to Sevy and Varacallo (2020), This is possible by using a reflex hammer to feel a tingling or electrical shock-like sensation.
Skin: No positive sign
Diagnostic results: Based on assessing the patient and her presentation, the relevant diagnostic investigation will be electromyography, where electrodes are tapped to the skin (Kothari, 2021). A shock is passed to the median nerve to prove if electrical impulses slow at the carpal tunnel.
A wrist X-ray can also be relevant to rule out arthritis and a fracture (Kothari, 2021).
ASSESSMENT: The diagnosis is carpal tunnel syndrome. ICD-10-CM G56.00.
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
The plan for this patient will be wrist splinting to hold the wrist, aiding to relieve the symptoms of numbness, pain and tingling. Non-steroidal inflammatory drugs can also play a role in managing this patient to relieve pain (Kothari, 2021). A cortisone injection can as well be used to relieve pain. If the patient does not respond to treatment and gets worse, surgery can be the definitive treatment.
Differential Diagnosis
The diagnosis would be carpal tunnel syndrome for this patient because of the patient's presentation. The ache on the fingers and hands is associated with numbness and tingling sensation, the main symptom of carpal tunnel syndrome (Wipperman & Goerl, 2016). The next differential diagnosis is carpometacarpal arthritis of the thumb which also presents with pain and numbness of the thumb (Wipperman & Goerl, 2016). Additionally, numbness on the index and middle finger may be caused by cervical radiculopathy; hence it can be a differential diagnosis for the patient. Flexor carpi radialis tenosynovitis can also be a differential diagnosis as the patient has tenderness and pain on the thumb (Wipperman & Goerl, 2016). Wrist tendonitis can also occur in the wrist can be a differential for this patient as it presents with intense and sharp pain making one experience weakness in activities like gripping. Lastly, repetitive strain injury can also be differentials for the patient as the patient presents with pain, weakness and tingling as it happens in the condition.
References
Kothari, M. J. (2021). Carpal tunnel syndrome: Treatment and prognosis. UpToDate, Waltham, MA [Acedido a 31 de janeiro de 2021]. Disponível em: https://www. update. com/contents/carpal-tunnel-syndrome-treatment--and-prognosis.
Sevy, J. O., & Varacallo, M. (2020). Carpal Tunnel Syndrome. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448179/
Wipperman, J., & Goerl, K. (2016). Carpal tunnel syndrome: diagnosis and management. American family physician, 94(12), 993-999.
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