Assessing Neurological Symptoms Assignment Paper

Assessing Neurological Symptoms Assignment Paper

Patient Information:

Initials: J.D.

Age: 48

Sex: Male

Race: Not specified

Subjective:

Chief Complaint:

Numbness and tingling in left toes

Numbness in the right heel and tingling sensation.

HPI

A 48years old male known Diabetes mellitus type 2 patient presented with:

• Location (L): Numbness specifically localized in his left toes and the heel of his right foot.
• Onset: Symptoms have been gradually worsening over the past few weeks, indicating a progressive nature of the condition.
• Character: The patient describes the sensation as numbness, accompanied by a tingling feeling, suggestive of sensory disturbances.
• Associated Signs and Symptoms: Alongside numbness and tingling, the patient reports difficulty in sensation while walking, implying functional impairment and occasional discomfort in the affected areas.
• Timing: Symptoms have been ongoing for several weeks, suggesting a chronic rather than acute presentation.
• Exacerbating/Relieving Factors: The patient experiences discomfort exacerbated by activities such as walking, indicating increased sensory disturbance during physical exertion.
• Severity: The severity of symptoms is significant enough to cause discomfort and functional limitations, as evidenced by the patient’s report of difficulty in sensation and pain while walking. Assessing Neurological Symptoms Assignment Paper
  

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Current Medications:

The patient has been on metformin 1000mg once daily for diabetes management for the past five years.

Allergies:

No reported allergies

PMHx:

The patient is a Diabetic mellitus type 2 patient diagnosed five years ago.

No history of major surgeries.

Social Hx:

The patient is an Office clerk living with his spouse and two children. He is a non-smoker and occasionally takes alcohol. The patient actively practices health promotion measures, including consistently using car seat belts and operational smoke detectors at home.

Fam Hx: Assessing Neurological Symptoms Assignment Paper

Mr. J.D.’s father had type 2 diabetes, while his mother has hypertension.

No other significant family history.

Review of Systems (ROS):

• GENERAL:

He repudiates fever, chills, nocturnal sweats, or unintentional weight loss.

He reports infrequent fatigue but attributes it to his busy work schedule.

• CARDIOVASCULAR (CVS):

He has neither angina, palpitations, nor edema.

• RESPIRATORY:

He denies shortness of breath, cough, or wheezing.

GASTROINTESTINAL (GIT):

He has no complaints of abdominal discomfort, vomiting, or changes in bowel habits.

• GENITOURINARY(GUT):

No urinary frequency, urgency, dysuria, or hematuria reported.

The last prostate exam was one year ago, and was normal.

• MUSCULOSKELETAL(MS): Assessing Neurological Symptoms Assignment Paper

He has joint pain sensation, rigidity, or swelling.

• SKIN:

There is no history of skin outbreaks, injuries, or skin changes.

Reports occasional dry skin, especially during winter months.

• PSYCHIATRIC:

He denies a history of depression, anxiety, hallucinations, or suicidal thoughts.

There were no reported significant stressors.

• ENDOCRINOLOGIC:

He denies cold or heat intolerance, increase in urination rate or excessive thirst.

Objective (O)

1. Physical exam:

General: He is responsive, oriented and in no obvious respiratory distress.

2. Neurological Examination:

• Mental Status: Attentive and oriented to person, place, time, and situation. Speech is fluent and coherent, with no evidence of aphasia or confusion.
• Cranial Nerves: Intact bilaterally. No facial asymmetry or abnormal facial movements were noted. Pupils are equal and reactive to light. Extraocular movements are intact.
• Motor Exam: Muscle strength 5/5 in all extremities. There is no evidence of tremors or involuntary movements: normal muscle tone and bulk.
• Sensory Exam: Decreased sensation to light touch noted in the left toes and right heel. Pinprick and temperature sensation intact. No signs of allodynia or hyperesthesia.
• Reflexes: Deep tendon reflexes (patellar, Achilles) are brisk and symmetrical bilaterally. No pathological reflexes are present.
• Coordination and Gait: Finger-to-nose and heel-to-shin tests normal bilaterally. Gait is stable and coordinated without any signs of ataxia. Assessing Neurological Symptoms Assignment Paper

3. Dermatologic:

No signs of ulceration or infection on feet.

Diagnostic results:

Fasting blood glucose: 180 mg/dL (elevated)

HbA1c: 8.5% (increased)

Assessment (A)

Differential Diagnoses:

• Diabetic Neuropathy:

Given the patient’s history of diabetes mellitus type 2 and elevated HbA1c, diabetic neuropathy is a likely cause of the numbness and tingling sensation in the feet. Evidence by: Studies have consistently shown a strong association between prolonged hyperglycemia and the development of diabetic neuropathy (Feldman et al., 2019).

• Peripheral Neuropathy:

Peripheral neuropathy can result from various etiologies, including metabolic disorders, autoimmune diseases, and infections. Given the patient’s diabetes, diabetic peripheral neuropathy remains a primary consideration. Evidence by: Research indicates that diabetes is one of the leading causes of peripheral neuropathy, affecting up to 50% of patients with diabetes (Joshua & Misri, 2022).

• Lumbar Radiculopathy:

Compression or irritation of lumbar nerve roots can lead to symptoms of numbness and tingling in the lower extremities. Given the patient’s complaints, lumbar radiculopathy should be considered, although less likely than diabetic neuropathy. Evidenced by clinical guidelines recommend an MRI of the lumbar spine to evaluate for radiculopathy in patients presenting with lower extremity symptoms (Liyew, 2020).

• Vitamin B12 Deficiency:

Deficiency in vitamin B12 can lead to peripheral neuropathy and sensory disturbances. Although less common, it should be considered, especially if the patient’s diet is deficient in vitamin B12-rich foods. Evidenced by: Studies have shown a correlation between vitamin B12 deficiency and peripheral neuropathy, emphasizing the importance of assessing serum vitamin B12 levels (Gwathmey & Grogan (2020)

• Peripheral Vascular Disease:

Decreased blood flow to the lower limbs could result in sensory disturbances such as numbness and tingling. Given the patient’s diabetes and risk factors for vascular disease, peripheral vascular disease should be included in the differential diagnosis. Evidenced by: Doppler ultrasound is recommended to assess vascular status in patients with suspected peripheral vascular disease (Rosenberg, 2020).

Plan:

Further management:

Initiate aggressive glycemic control through medication adjustment and lifestyle modifications.

Refer to a neurologist for further evaluation and management of diabetic neuropathy.

Consider additional testing for vascular and thyroid function too.

References

Feldman, E. L., Callaghan, B. C., Pop-Busui, R., Zochodne, D. W., Wright, D. E., Bennett, D. L., … & Viswanathan, V. (2019). Diabetic neuropathy. Nature reviews Disease primers, 5(1), 41.                                                                                https://doi.org/10.1038/s41572-019-0092-1

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Gwathmey, K. G., & Grogan, J. (2020). Nutritional neuropathies. Muscle & nerve, 62(1), 13-29. https://doi.org/10.1002/mus.26783

Joshua, A. M., & Misri, Z. (2022). Peripheral Nerve Disorders. In Physiotherapy for Adult Neurological Conditions (pp. 621-729). Singapore: Springer Nature Singapore. https://doi.org/10.1007/978-981-19-0209-3_11

Liyew, W. A. (2020). Clinical presentations of lumbar disc degeneration and lumbosacral nerve lesions. International journal of rheumatology, 2020.           https://doi.org/10.1155/2020/2919625

Rosenberg, L. (2020). Peripheral Arterial Disease (PAD)/Vascular Disease. In Encyclopedia of Behavioral Medicine (pp. 1649-1649). Cham: Springer International Publishing. https://doi.org/10.1007/978-3-030-39903-0_1278 Assessing Neurological Symptoms Assignment Paper

Episodic/Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

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

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7^th edition formatting.