Case Study Assignment: Assessing Neurological Symptoms Focused SOAP Note Template

 Episodic/Focused SOAP Note Neurologic Disorders

 

Episodic/Focused SOAP Note Template

Patient Information:

Mr. J. A., a 67-year-old non-Hispanic

S.

CC (chief complaint) “My father is very forgetful.”

HPI: A 67-year-old patient brought to the healthcare facility by his daughter complains of being forgetful. The problem has lasted for over a month, and the last episode, where he drove to the store and called her daughter to explain the direction back home, evoked the clinic visit. The primary informant is the daughter. She complains that her father is very forgetful and has repeatedly lost his car keys. He reports that the symptoms worsened in the recent month after he began his alcohol withdrawal program. He is often irritable and agitated. His remote memory is intact, and he has problems recalling recent events. He cannot explain how he got to the facility and denies forgetfulness.

Current Medications: Insulin 10IU SC TDS (after meals, last taken today morning). Diazepam 5mg tablets PO TDS

Allergies: Allergic to dust and cat fur (he has no pets). He develops a cough, nasal congestion, stuffiness, and rhinorrhea on exposure. Denies any food and drug allergies

PMHx: Diagnosed with epilepsy at six, which subsided over time. The patient was also admitted at 17 following fracture femurs after an RTA. He sustained minor head injuries and underwent an intramural nail insertion surgery. He was an alcoholic, started at 50 after losing his wife of 25 years, and is currently on a withdrawal program.
Soc Hx: Mr. J. A. is a retired teacher who loves to go shopping and on road trips with his family and friends. He currently lives with his daughter and the house help; his eldest son is married. He is an active smoker but verbalizes the urge to cease smoking. He was an alcoholic but has been in AA and currently taking diazepam to manage withdrawal symptoms. Mr. J. A. uses seat belts when driving or in public transport, has active smoke detectors in the house, and has a gun for personal protection. He has a strong social support system consisting of his daughter and the church clergy.

Fam Hx: Paternal grandfather had epilepsy and died of a stroke at 68. His paternal grandmother had diabetes and died of an RTA at 70. Father was alcoholic, hypercholesterolemic, and succumbed to a stroke at 80. Brother, 76, is hypercholesterolemic and epileptic. Sister, 65, has diabetes and was diagnosed with breast cancer six years ago, which resolved after surgery. Her daughter, 25, was diagnosed with MDD 2 years ago, which resolved after treatment.

ROS:

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

HEENT:  Eyes: Denies visual changes, pain, or drainage. Ears: Denies auditory changes, pain, or discharge. Nose: Denies pain, congestion, and runny nose. Throat:  Denies sore throat, pain in swallowing.

SKIN:  Denies itchiness, rashes, or lesions.

CARDIOVASCULAR:  Denies chest pain, pressure, or discomfort. Denies a racing heart or edema

RESPIRATORY:  Denies SOB, cough, fast breathing, or sputum production.

GASTROINTESTINAL:  Denies bloating, indigestion, abdominal upset, nausea, vomiting, diarrhea, or constipation

GENITOURINARY:  Denies any pain in micturition and or blood in the urine. Sexually inactive for a while with no recent sexual drive changes

NEUROLOGICAL:  Daughter reports recent changes in coordination with keys and other items falling from his hands unawares. Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. Denies bowel or bladder control changes

MUSCULOSKELETAL: Reports occasional back pain and tiredness. Denies back and joint pain and joint stiffness.

HEMATOLOGIC:  Denies anemia, easy bleeding or bruising, reports blood coagulates first

LYMPHATICS: Denies having enlarged lymph nodes or any history of splenectomy

PSYCHIATRIC:  Reports a temporary depressive episode after losing his wife. Denies anxiety or other mental health illnesses.

ENDOCRINOLOGIC:  Denies excessive thirst, hunger, or urination, and cold or heat intolerance

ALLERGIES: Reports a recent history of allergic rhinitis six weeks ago. Denies other recent allergic reaction episodes

O.

Physical exam:

Vitals: BP-125/89: P-88: T: 36.7⁰C: RR: 17 Pain: 0/10, SpO₂ – 98% of room air

General: The patient appears irritated and confused but appropriately dressed for the occasion and weather. He is well-oriented to place and person but is disoriented to time and event. He appears emaciated and sad.

Head: The patient has grey hair with visible hair loss and a resending hairline. A visible scar on the left parietal aspect of the skull

Neck: Trachea midline, no enlarged cervical lymph nodes

Chest: Symmetrical rising on breathing. Resonant to percussion, no crackles or wheezes, and vesicular breath sounds auscultated. S1 and S2 present, no S3, S4, murmurs, or bruits, and the apical pulse is 88

Abdomen: Globular shape, no scars, flank discoloration, or bruising. Bowel sounds are present in all quadrants.

Extremities: Symmetrical with appreciable muscle tone

Neuromuscular: Muscle and tendon reflexes present. Tinetti Balance Assessment positive, patient-oriented to persons, place, and disoriented to time and occasion, Glasgow coma scale score of 13, Mini-Mental Status Examination (MMSE)- reveals distorted immediate recall and retention and recent memory. Back muscle mild pain and tiredness with no gait changes

Psychiatric/MSE: All muscles with appreciable muscle tone. Immediate recall and retention memory distorted- the patient cannot recall a short story narrated. Recent memory distorted- patient remembers scanty details of their previous day’s activities.

Diagnostic results: Head CT scan- helps differentiate idiopathic amnesia from amnesia resulting from brain degeneration and trauma. Head CT and MRI scans help study brain activity and unearth any abnormal activity. In addition, an electroencephalogram will help understand brain activity. Full hemogram tests to determine thiamine and other hormone and electrolyte levels will help rule out other conditions.

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses)

The presumptive diagnosis is anterograde amnesia. Anterograde amnesia is a transient idiopathic condition whose cause is not permanent, such as those caused by degenerative brain disorders (Garland et al., 2021). The patient presents with various confounders that could predispose an individual to the condition. He is an active smoker and is currently on diazepam to manage alcohol withdrawal syndrome. Some causes of the condition are psychotropic medications and traumatic brain injury. Patients with this condition should be attended to with attention due to the risk of self-harm, especially forgetfulness.

Drug-induced amnesia is a possible diagnosis for this patient. Benzodiazepines are medications known for inducing amnesia. Jain (2021) notes that benzodiazepines interfere with memory formation, causing difficulty in remembering recent events under the drug’s influence. Memory returns when the drug’s influence wears off. Mr. J. A’s condition began earlier before starting the medication. In addition, his memory of recent events is simply absent, not just forgotten.

The client could also be suffering from transient epileptic amnesia. The condition is rare and results from temporal lobe epilepsy and can be defined as brief and frequently occurring symptoms of amnesia. The patient’s caregiver reports several recurring episodes of amnesia, such as losing keys. An assessment of the patient these client reveals a lack of immediate recall and retention and recent memory, ruling out the condition (Ball et al., 2019). Physical exam, including psychiatric and mental health examination, helps diagnose underlying conditions and remedy them

Another possible diagnosis is transient global amnesia. The condition refers to an episode of memory loss that is sudden and idiopathic without a physical or neurologic cause (Sparaco et al., 2022). Patients often forget where they are and how they got there; the episodes last less than 24 hours. Alessandro et al. (2019) note that the condition is associated with other underlying conditions, such as hippocampal interference and migraines, which are common in individuals with transient global amnesia. An MRI or CT scan can help diagnose the condition by studying the brain structure. Mr. J. A. has exhibited similar symptoms, but his condition has been recurrent, and the client cannot create memories at all. Memory loss in TGA is episodic, and the client can remember the details, which is not the case for this patient, ruling out the condition.

The client could have suffered from dissociative amnesia. The condition results from a past psychologically painful event, such as losing a loved one. The condition manifests through episodic memory loss that occurs over an hour, a day, days, and even years, depending on the intensity of the psychological pain (Manguilli et al., 2022). However, the condition leads to a total blackout with memory loss, especially of the event and their identity. However, the patient remembers their details and identity and has a vivid remote memory ruling out the condition. In this case study, the patient and her daughter present limited knowledge and gaps, and it is impossible to rule out these conditions entirely. Thus, further clinical and diagnostic interventions are vital before diagnosing this patient.

P.

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

References

Alessandro, L., Calandri, I. L., Suarez, M. F., Heredia, M. L., Chaves, H., Allegri, R. F., & Farez, M. F. (2019). Transient global amnesia: clinical features and prognostic factors suggesting recurrence. Arquivos de Neuro-Psiquiatria, 77, 3-9. https://doi.org/10.1590/0004-282X20180157

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby as one of the references

Garland, M. M., Vaidya, J. G., Tranel, D., Watson, D., & Feinstein, J. S. (2021). Who Are You? The Study of Personality in Patients With Anterograde Amnesia. Psychological Science, 32(10), 1649-1661. https://doi.org/10.1177/09567976211007463

Jain, K. K. (2021). Drug-Induced Disorders of Memory and Dementia. In Drug-induced Neurological Disorders (pp. 209-231). Springer, Cham. https://doi.org/10.1007/978-3-030-73503-6_14

Mangiulli, I., Otgaar, H., Jelicic, M., & Merckelbach, H. (2022). A critical review of case studies on dissociative amnesia. Clinical Psychological Science, 10(2), 191-211. https://doi.org/10.1177/21677026211018194

Sparaco, M., Pascarella, R., Muccio, C. F., & Zedde, M. (2022). Forgetting the unforgettable: transient global amnesia part I: pathophysiology and etiology. Journal of Clinical Medicine, 11(12), 3373. https://doi.org/10.3390/jcm11123373