Neurological Health Assessment Essay Paper

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INSTRUCTIONS TO WRITER::::::: SOAP NOTE SHOULD BE STRICTLY VV DETAILED AND PLAGIARISM FREE

Patient Exam : Assess the Neurological system of Tina Jones, a Digital Standardized Patient. Interview and examine the patient, document your findings, and complete post-exam activities. On average, this assignment should take from 90-120 minutes to complete
Assignment Description: Assess the Neurological system of Tina Jones, a Digital Standardized Patient. Interview and examine the patient, document your findings, and complete post-exam activities. On average, this assignment should take from 90-120 minutes to complete Neurological Health Assessment Essay Paper

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1. You need to submit a SOAP note – subjective, objective, assessment and PLAN. Documentation should be completed using a Word document. PLEASE PAY ATTENTION TO THIS:::: Working Diagnosis (with ICD 10 code)â€“ what do you think the problem is, provide supporting data (cite).
Type in N/A on the Shadow Health documentation box. See SOAP Note rubric and Focused SOAP note template guide â€“ writer will work exactly on this. I have attached these in files section.

2. Please log on to my shadow health from my institution page. Its on BlackBoard. My log in credentials are: username – virmanip
Password – Chinoo@1000 Please use these credentials to log in the webpage mentioned in next point.

3. instituition is William Paterson University. webpage to get in : Neurological Health Assessment Essay Paper https://bb.wpunj.edu/ultra/courses/_28718_1/cl/outline

4. Interview is being conducted by NP – Puneet Virmani, so intorduce yourself as Ms. Puneet while conducting an assessment on Gastrointestinal

5. Deadline is 2 days please. Must remember.

6. Follow RUBRIC v v strictly in all excellent section Boxes. And Writer will work strictly on the template for SOAP documentation provided and attached in files section. Writer will Submit the Shadow health part. I will submit the word document part.

7. V V IMPORTANT :::: SOAP NOTE TEMPLATE GUIDE is attached. Writer should work strictly on that using that guide in his own words. SOAP note must be in a separate word document attached to my order. Type N/A on the Shadow Health document

DO NOT COPY WORDINGS FROM DOCUMENTATION ON SHADOW HEALTH
::::::::::::::::::::EVERY WORD ON SOAP DOC SHOULD BE AND MUST BE PLAGIRIASM FREE::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

8. A score of 100% is must

Subjective data

Chief complaint: headache and neck stiffness

History of presenting illness: tina jones is a 28years old African American female presenting with a headache. The headache is of acute onset, at the bilateral temporal region, radiates to the neck, and is dull in nature. The patient reports intermittent pain because it lasts about two hours. The pain’s trigger is exertion, which is relieved by taking Tylenol 650mg. The pain does not affect her daily activities. The associated symptoms are neck pain, stiffness, and a feeling of fullness. The onset of the symptoms was four days after she was a restrained passenger in a parking lot accident at a speed of 10km/hr. The patient denies loss and changes of consciousness, and photophobia.

Current medication: Tylenol 650mg prn for headache. Metformin 500mg twice daily, and Lantus 10Iu SC for diabetes mellitus. Ventolin 200mcg metered dose inhaler and montelukast 10mg po prn for asthma.

Past medical history: the patient is hypertensive, which she controls by restricting dietary sodium, diabetes mellitus, and asthma. She has had hospital admissions twice due to status asthmaticus at the age of 20 years and diabetes ketoacidosis at the age of 24 years. She regularly monitors her blood sugars. Her immunization schedule is up to date. Neurological Health Assessment Essay Paper

Past surgical history: none

Allergies: the patient experiences symptoms of acute asthma exacerbation when exposed to dust, smoke, cold weather, pollen, and fur. She relieves the symptoms by taking montelukast and Ventolin inhalers. She denies food, latex, and drug allergies.

Social history: the patient is single and has no child. She lives with her younger sister. She works as a banker. She has an undergraduate degree in commerce and a post-graduate master’s in finance. She enjoys reading, career coaching, and writing articles. She drinks one glass of wine in the evening. She enjoys taking fries and deep-fried chicken. She denies the use of drugs and substance abuse.

Family history: the patient is the firstborn in a family of three. Her father is 58 years old living with diabetes mellitus, hypertension, and coronary heart disease. Her mother is 55 years old and has asthma and osteoarthritis. Her siblings have recurrent allergic rhinitis and are obese. She denies a family history of cancer and mental health diseases.

Review of systems

General: the patient denies fatigue, weight loss or gain, fever, sweating, chills, and rigors.

HEENT: the patient has a bilateral temporal headache associated with neck pain and stiffness. She has had deteriorating blurring of vision after reading for an extended duration. She denies eye itchiness and tearing, loss of hearing, tinnitus, vertigo, discharge, earache, rhinorrhea, sinus pressure, sneezing, and itchiness. Neurological Health Assessment Essay Paper

Musculoskeletal system: the patient denies muscle weakness, muscle pain, difficulties with a range of motion, joint instability, and swelling.

Neurologic: the patient denies loss of sensation, numbness, tingling, weakness, paralysis, fainting, blackouts, seizures, changes in bowel emptying, sleeping pattern, appetite, coordination, and concentration.

Respiratory system: the patient denies coughing, chest pain, runny nose, sputum production, wheezing, and difficulties in breathing.

Cardiovascular system: the patient denies shortness of breath, dyspnea, syncope, orthopnea, and paroxysmal nocturnal dyspnea.

Gastrointestinal system: the patient denies abdominal pain, loss of appetite, nausea, vomiting, diarrhea, constipation, and reflux.

Genitourinary system: the patient has no dysuria, hematuria, polyuria, vaginal discharge, and lower abdominal pain.

Hematological system: the patient denies fainting episodes, bleeding tendencies, fever, and shortness of breath.

Psychiatric: the patient has no depressive mood, sadness, hallucination, agitation, and restlessness.

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Objective Data

Physical examination: the patient is alert. She has no pallor, jaundice, cyanosis, edema, dehydration, or lymphadenopathy.

Vitals: her temperature is 98.6F, her blood pressure at 120/70mmhg, her pulse rate at 86 beats per minute, her respiratory rate at 20cycles per minute, her height is 5’2, weight at 126Ibs, and her BMI of 23kg/m2.

HEENT: the head is standard cephalic with no signs of trauma. The eyes have bilateral pupil expansion and reaction to light. There is equal distribution of hair to the eyes and brows. The conjunctiva is pink with no lesions of the white sclera. The EOMs are intact bilaterally with no nystagmus. There are mild retinopathic changes on the right. The left fundus has sharp disc margins and no hemorrhages. The eye vision is 20/40 on the right and 20/20 on the left with corrective lenses. The TMS are intact and pearl-gray bilaterally with a positive light reflex. The frontal and maxillary sinuses are nontender to palpation. The nasal mucosa is moist and pink, with the septum at the midline. The oral mucosa is moist without ulcerations or lesions, the uvula rises midline on phonation, and the gag reflex is intact Neurological Health Assessment Essay Paper

Respiratory System: the chest has symmetrical movement during respiration. There is a resonant percussion note, and vesicular breath sounds. There are no crackles, wheezing, rhonchi, and stridor.

Cardiovascular system: the peripheral pulse is present regular rate and rhythm. The heart sounds are present at 5^th intercostal space with no murmurs and added sounds. There are no palpable heaves and thrills.

Gastrointestinal system: the abdomen is round with no flank fulness. There are no therapeutic marks and striae. The bowel sounds are present in all the four quadrants. There are no areas of tenderness and organ enlargement. There is a tympanic percussion note with no shifting dullness.

Assessment

The patient presents with an acute intermittent headache that is dull at the bilateral temporal region radiating to the neck and associated with neck stiffness. The patient has progressive blurring of vision associated with prolonged reading. On examination, the right eye vision is 20/40; she has a sharp disc margin and mild retinopathy changes on the right eye. She has pre-existing chronic diseases, diabetes mellitus, hypertension, and asthma. The differential diagnoses are post-traumatic headache, muscle contraction tension headache, temporal arteritis, and migraine headache Neurological Health Assessment Essay Paper

Differential Diagnoses

Post-traumatic headache G44.309 is a pain in the head at the point of impact during the trauma. The pain occurs within 7days after the injury or after gaining consciousness. The pain is dull, of acute onset, and lasts 30 minutes to three hours. The pain is aggravated by exertion or movement and relieved by resting and taking pain medication. The severity of the pain depends on the intensity of the trauma. Associated symptoms of post-traumatic headache are photophobia, seizures, loss of consciousness, nausea, vomiting, dizziness, loss of concentration, and altered mental status (Labastida-Ramírez et al., 2020)Neurological Health Assessment Essay Paper. The pain may radiate to the neck, chest, and upper limbs depending on the force of the trauma. This patient has a post-traumatic headache because she has a headache that radiates to the neck and causes neck stiffness. The headache has been intermittent, lasting at least two hours daily since the injury. Causes of headache and neck stiffness with no neurological symptoms because the intensity of the damage of low, and there was a sudden jerk forward and backward whiplash of the muscles and ligaments of the neck and the head.

Muscle contraction tension headache G44.209 is the most common primary headache affecting more than 80% of adults. The peri-cranial musculatures trigger the headache because the contraction causes hypoxia, leading to the constant pain. The pain radiates to the neck due to the tightening of the muscles of the sub-occipital region. Muscle contraction tension headache is associated with neck pain and stiffness, insomnia, and focal neurological symptoms such as paralysis, weakness, loss of muscle tone, and tremors (Shah et al., 2022). The patient presents with symptoms of headache and neck stiffness due to trauma. However, this is not the diagnosis because the patient has no positive symptoms for focal neurological signs. Additionally, the patient has not met the criteria for the international classification of headache disorders of tension headache, such as having more than ten episodes lasting up to seven days pulsating the quality of the headache.

Temporal neuritis M31.6 is the inflammation of the cranial arteries leading to musculoskeletal, neurological, and ophthalmic complications. Temporal neuritis results from injury to the endothelial system due to trauma, infection, and autoimmune response. The presenting symptoms are bilateral or unilateral temporal headache, fever, malaise, temporal tenderness, neck pain, jaw claudication, progressive blurring of vision and vision loss, weakness, sore throat, hoarseness of voice, and Raynaud’s phenomenon (Ameer et al., 2022). The patient presents with progressive vision blurring and mild retinopathy in her right eye. Additionally, she has a bilateral temporal headache and neck pain with stiffness. These symptoms are due to the involvement of trigeminal nerve injury in temporal neuritis. However, this is not the diagnosis because the patient denies fever and malaise and has no tenderness at the temporal region Neurological Health Assessment Essay Paper.

Plan

Diagnostic Investigation

Erythrocyte sedimentation and c-reactive protein rate to rule out temporal neuritis and other chronic diseases associated with headaches. Head ct scan to rule out cerebral hemorrhages and neoplasms. Cerebral spinal fluid analysis to rule out meningitis.

Treatment

Ibuprofen 800mg po tds for three days with meals to relieve the pain.

The patient should continue with her metformin and lantus to control her blood sugar levels.

Bed rest to prevent the trigger of headache

Relaxation and posture therapy to relieve the symptoms

, massage and acupuncture of the neck to relieve pain and stiffness

Review the patient after one week to monitor the signs and the effectiveness of the medication.

Patient education

Educate the patient on the headache symptoms, triggers, and pain management at home. The patient should maintain a comfortable posture to prevent pain and stiffness Neurological Health Assessment Essay Paper.

References

Ameer, M. A., Peterfy, R. J., & Khazaeni, B. (2022). Temporal Arteritis. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459376/

Labastida-Ramírez, A., Benemei, S., Albanese, M., D’Amico, A., Grillo, G., Grosu, O., … & Martelletti, P. (2020). Persistent post-traumatic headache: a migrainous loop or not? The clinical evidence. The Journal of Headache and Pain, 21(1), 1-15. https://doi.org/10.1186/s10194-020-01122-5

Shah N, Hameed S. Muscle Contraction Tension Headache. [Updated 2022 Oct 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562274/

INSTRUCTIONS TO WRITER:::::::

Assignment Description: Assess the Neurological system of Tina Jones, a Digital Standardized Patient. Interview and examine the patient, document your findings, and complete post-exam activities. On average, this assignment should take from 90-120 minutes to complete

You need to submit a SOAP note – subjective, objective, assessment and PLAN. Documentation should be completed using a Word document. PLEASE PAY ATTENTION TO THIS:::: Working Diagnosis (with ICD 10 code)– what do you think the problem is, provide supporting data (cite)Neurological Health Assessment Essay Paper.

Type in N/A on the Shadow Health documentation box. See SOAP Note rubric and Focused SOAP note template guide – writer will work exactly on this. I have attached these in files section.

Please log on to my shadow health from my institution page. Its on BlackBoard. My log in credentials are: username – virmanip

Password – Chinoo@1000 Please use these credentials to log in the webpage mentioned in next point.

instituition is William Paterson University. webpage to get in : https://bb.wpunj.edu/ultra/courses/_28718_1/cl/outline
Interview is being conducted by NP – Puneet Virmani, so intorduce yourself as Ms. Puneet while conducting an assessment on Gastrointestinal
Deadline is 2 days please. Must remember.
Follow RUBRIC v v strictly in all excellent section Boxes. And Writer will work strictly on the template for SOAP documentation provided and attached in files section. Writer will Submit the Shadow health part. I will submit the word document part.
V V IMPORTANT :::: SOAP NOTE TEMPLATE GUIDE is attached. Writer should work strictly on that using that guide in his own words. SOAP note must be in a separate word document attached to my order. Type N/A on the Shadow Health document

DO NOT COPY WORDINGS FROM DOCUMENTATION ON SHADOW HEALTH

::::::::::::::::::::EVERY WORD ON SOAP DOC SHOULD BE AND MUST BE PLAGIRIASM FREE::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

A score of 100% is must

FOCUSED SOAP Note Format

SUBJECTIVE

CC – the reason for the visit as stated in the patient’s own words

Example: “I have a painful rash on my left side that started 2 days ago.”

HPI (History of Present Illness) – include symptom dimensions, chronological narrative of patient’s complains. Use PQRST or OLDCARTS mnemonic to guide you in obtaining pertinent information. If the information is obtained from other sources, always identify source.

PMH (Pertinent past medical history) Neurological Health Assessment Essay Paper

Medications – Current medications (list with daily dosages).

Allergies

Pertinent Family History, Social History and other subjective data if relevant to the patient’s presenting problem and diagnosis.

ROS (Pertinent review of systems) – a system- based list of questions that help uncover symptoms not otherwise mentioned by the patient. In a focused SOAP note, only include systems pertinent to the presenting problem and/or diagnosis.

OBJECTIVE

Vital signs

PE – focused physical exam finding limited to systems pertinent to the problem

Laboratory or diagnostic data if applicable

ASSESSMENT (Problem List)

Differential diagnoses (with ICD 10 code)– distinguishing a particular disease or condition from others that present with similar clinical features. Identify 2. Provide a brief rationale (3-4 sentences) and cite – rationale should provide data that support your differential diagnoses – presentation, PE finding and/or lab/diagnostic test results that make it similar to the diagnosis and explain the difference between the differential and working diagnoses and/or the laboratory/diagnostic tests that would make the diagnosis.

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Working Diagnosis (with ICD 10 code)– what do you think the problem is, provide supporting data (cite).

PLAN

This has to be evidence based (cite) using the latest clinical guideline. This should include pharmacologic, non-pharmacologic, education, referrals and follow-up – when applicable. The plan should be personalized and appropriate for the patient. Neurological Health Assessment Essay Paper

Cite and provide references.