NURS 6512 Week 9 Assessment Of Cognition And The Neurologic System To Prepare By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor. Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

NURS 6512 Week 9 Assessment Of Cognition And The Neurologic System To Prepare By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor. Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

Episodic/Focused SOAP Note Template

Patient Information:

Initials: H.F.                Age: 47 Years             Sex: Female                Race: Caucasian

S.

CC (chief complaint): “I am experiencing pain in my right wrist”

HPI: H.F., a 47-year-old Caucasian female with obesity, sought medical attention at the clinic due to her primary concern of experiencing pain in her right wrist, accompanied by sensations of numbness and tingling in the index, middle finger, and thumb. The patient has provided an account of experiencing these symptoms approximately fourteen days prior. Nevertheless, she expresses apprehension regarding the discomfort, as it causes her to inadvertently release her hairstyling implements.

Location: Right wrist

Onset: two weeks ago

Character: Numbness and pain in her right wrist

Associated signs and symptoms: Thumb, middle, and index finger tingling

Timing: the whole day

Exacerbating/ relieving factors: Worse while doing tasks with the wrist joint. When the wrist is stationary, the discomfort is reduced.

Severity: 6/10

Current Medications:

• Ibuprofen at a dosage of 400mg taken orally as needed,
• Hydrochlorothiazide at a dosage of 25mg taken orally every morning
• Amlodipine at a dosage of 10mg taken orally once daily.

Allergies: Allergic to sulfur. No environmental or food allergies.

PMHx: The patient exhibits obesity and has a documented history of hypertension.

• Immunization status: The patient has received all necessary vaccinations, including Tdap in October 2020, the Influenza Vaccine during the current season, and completed the COVID-19 Vaccines with Boosters in 2021.
• Surgeries: without any prior surgical history
• Hospitalization: There is no record of any hospitalizations.

Soc Hx: The patient is a hairdresser who works five blocks from her house in a neighborhood spa. She claims to have a history of sometimes consuming alcohol while smoking cigarettes. She does not, however, admit to using marijuana or any other illegal substance. She presently lives as a family with her husband and three kids. During her free time, she enjoys singing and reading. She exercises by taking the dog for a 30-minute walk every evening. She affirms that she eats a healthy diet and sleeps well for around 8 hours each night.

Fam Hx: The patient has two siblings, the younger of whom has just received an asthma diagnosis while the other is well. Both of her parents are still living; the mother has a history of T2DM and HTN, while the father has a history of HTN and esophagostomy. She is unaware of the medical history of her grandparents.

ROS:

GENERAL: denies any symptoms of heat or cold sensitivity, reduced appetite, sluggishness, chills, fever, or recent weight changes.

HEENT: Head: denies experiencing seizures, headaches, or dizziness. Eye: denies any discomfort, discharge, vision disturbances, photophobia, or blurriness. Ear: denies discharge, tinnitus, discomfort, or hearing loss. Nose: denies having sneeze fits, sinus pain, a runny nose, or nose bleeding. Throat: denies pain, swallowing issues, or voice hoarseness.

SKIN: denies rash or itching.

CARDIOVASCULAR: denies having orthopnea, arrhythmias, elevated blood pressure, or palpitations.

RESPIRATORY: denies having a cough, producing phlegm, having breathing problems, or breathing quickly.

GASTROINTESTINAL: denies experiencing vomiting, heartburn, heartburn pain, discomfort, or abdominal distention.

GENITOURINARY: denies having hematuria, vaginal discharge, incontinence, dysuria, oliguria, frequent urination, or burning pain.

NEUROLOGICAL: denies experiencing ataxia, a headache, paralysis, syncope, or abnormalities in bowel or bladder control. reports tingling and numbness in the middle, index, and thumb fingers.

MUSCULOSKELETAL: a right wrist ache is reported. denies muscular pain, joint stiffness, or joint swelling. demonstrates the complete range of motion in other joints.

HEMATOLOGIC: denies bleeding issues, easy bruising, or anemia.

LYMPHATICS: denies splenectomy or lymphadenopathy.

PSYCHIATRIC: denies experiencing hallucinations or other psychological symptoms such as anxiety, sadness, or thoughts of homicide or suicide.

ENDOCR