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3 pages/β‰ˆ825 words
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3 Sources
Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Research Paper
Language:
English (U.S.)
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MS Word
Date:
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$ 17.5
Topic:

Episodic/Focused Note on Patient Facing Anterograde Amnesia

Research Paper Instructions:

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.

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. 

Case 2: Forgetfulness (Last Name N-Z)

Asia brings her 67 year old father into the office stating he is very forgetful. He has lost his car keys several times. She also states he has driven to the store and called her asking for directions to get back home

 

Research Paper Sample Content Preview:


Episodic/Focused SOAP
Name
Institution
Course
Instructor
Date
Episodic/Focused SOAP
Patient information
N-Z is a 67-year-old white male.
S
CC: Forgetfulness
HPI: N-Z, a 67-year-old male, has become progressively forgetful. Initially, he would forget where he had placed his car keys. He drives to the store, but he forgets how to return home when he reaches there. Asia, the daughter, has realized that N-Z's forgetfulness is becoming a problem, although N-Z can still drive and manage his money.
Current medication: None
Allergies: None
PMHx: Immunization is up to date. Last received tetanus at 57 years
Soc Hx: Lives with a family member.
Fam Hx: None
ROS
GENERAL: Denies chills, fever, fatigue, or weight loss.
HEENT: Eyes: Has no red sclerae, or yellow sclerae, denies double vision, visual loss, or blurred vision.
ENT (Ears, Nose, and Throat): no hearing loss, congestion, or aching throat.
SKIN: No rash or irritation.
RESPIRATORY: No dyspnea, cough, or mucus
CARDIOVASCULAR: No chest discomfort, pressure, pain, or palpitations.
NEUROLOGICAL: No dizziness, no syncope, no paralysis, no headache, no ataxia.
HEMATOLOGIC: Denies anemia, bruising, or bleeding.
MUSCULOSKELETAL: Has pain in the left ankle. No stiffness or back pain.
PSYCHIATRIC: Denise has a history of anxiety or depression.
ALLERGIES: No history of rhinitis, asthma, urticarial, or dermatitis.
ENDOCRINOLOGIC: No polydipsia or polyuria.
O
Physical exam
VITALS: Weight: 81, Height (HT): 163CM, Body Mass Index (BMI): 20, Temperature: 36.9 oral, Heart rate (HR): 77, Blood Pressure (BP): 118/79, Oxygen Saturation (SpO2) 97%.
RESPIRATORY: No shortness of breath, cough, or sputum.
CARDIOVASCULAR: I heard regular and rhythm rates S1 and S2. There was no low-pitched sound S3 or S4. Capillary refill is less than 2 seconds. 2+ dorsalis Pedi's pulse.
NEUROLOGICAL: Awake but disoriented to situation, time, and place.
MUSCULOSKELETAL: Joints are free from swelling and deformity. Negative ankle drawer test on the left foot.
SKIN: soft, intact, and warm. There is no open wound or discoloration (ecchymosis).
Diagnostic results
Neuropsychological examination
This test measures how well a person's brain work. Some factors analyzed include reading, attention, reasoning, language usage, processing speed, and remembering (Ossenkoppele et al., 2021). N-Z requires this examination to identify the cause of the short-term memory change and frequency of losing items. Th

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