Posted: September 29th, 2022

A 20-year-old male complains of experiencing intermittent headaches

Group 1: CASE STUDY: A 20-year-old male complains of experiencing intermittent headaches.
CASE STUDY: A 20-year-old male complains of experiencing intermittent headaches.

A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse everywhere in the head, however the best depth and strain happens above the eyes and spreads by means of the nostril, cheekbones, and jaw.

Week 9 Project NURS 6512
You can be concentrate on Neurological Signs. Group 1 has Case examine 1 and Group 2 Numbness and Ache. You may have 2 required assignments for this Week.

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Project 1: Case Examine Project: Assessing Neurological Signs
To Put together for CASE STUDY: A 20-year-old male complains of experiencing intermittent headaches.

By Day 1 of this week, you can be assigned to a particular case examine for this Case Examine Project. Please see the “Course Bulletins” part of the classroom in your task out of your Teacher.
Additionally, your Case Examine Project needs to be within the Episodic/Centered SOAP Observe format moderately than the normal narrative type format. Check with Chapter 2 of the Sullivan textual content and the Episodic/Centered SOAP Template within the Week 5 Studying Sources for steering. Keep in mind that all Episodic/Centered SOAP notes have particular information included in each affected person case.
With regard to the case examine you have been assigned:

Overview this week’s Studying Sources, and contemplate the insights they supply in regards to the case examine.
Think about what historical past could be vital to gather from the affected person within the case examine you have been assigned.
Think about what bodily exams and diagnostic exams could be acceptable to assemble extra details about the affected person’s situation. How would the outcomes be used to make a analysis?
Establish a minimum of three attainable situations that could be thought-about in a differential analysis for the affected person.
The Case Examine Project

Use the Episodic/Centered SOAP Template and create an episodic/targeted be aware in regards to the affected person within the case examine to which you have been assigned utilizing the episodic/targeted be aware template offered within the Week 5 sources. Present proof from the literature to help diagnostic exams that may be acceptable for every case. Listing 5 completely different attainable situations for the affected person’s differential analysis, and justify why you chose every.

By Day 6 of Week 9

Submit your Project.

Submission and Grading Info

To submit your accomplished Project for evaluate and grading, do the next:

Please save your Project utilizing the naming conference “WK9Assgn1+final identify+first preliminary.(extension)” because the identify.
Click on the Week 9 Project 1 Rubric to evaluate the Grading Standards for the Project.
Click on the Week 9 Project 1 hyperlink. Additionally, you will be capable to “View Rubric” for grading standards from this space.
Subsequent, from the Connect File space, click on on the Browse My Laptop button. Discover the doc you saved as “WK9Assgn1+final identify+first preliminary.(extension)” and click on Open.
If relevant: From the Plagiarism Instruments space, click on the checkbox for I comply with submit my paper(s) to the International Reference Database.
Click on on the Submit button to finish your submission.
Pattern Strategy
A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse everywhere in the head, however the best depth and strain happens above the eyes and spreads by means of the nostril, cheekbones, and jaw

Take into consideration what type of background data you would wish to get from the affected person within the case examine that you’ve been assigned.
When taking the affected person’s medical historical past, it will have been useful to inquire additional in regards to the headache. The examiner must have relied extra closely on SOCRATES with a view to consider the headache. Based on Gregory (2019), the SOCRATES mnemonic is a ache Assessment device that’s extensively utilized by healthcare suppliers to help them in remembering key questions in regards to the affected person’s ache. [Citation needed] The start, the character, the related signs, the severity, or the elements which might be both aggravating or relieving. As well as, the affected person ought to have been questioned concerning the presence of any earlier head accidents, visible disturbances, dizziness, nausea, vomiting, photophobia, fever, sleep disturbances, neurological deficits, neck stiffness, tenderness within the temporal area, rash, or loss of weight.

Take into consideration what varieties of diagnostic exams and bodily examinations could be most acceptable for the affected person in an effort to discover out extra about their situation. How would the findings be included into the diagnostic course of?
Based on Lee et al. (2018), sufferers that suffer from headaches ought to bear a bodily examination as quickly as attainable to Help remove the likelihood of secondary headaches. A affected person who is available in complaining of headaches can have their important indicators monitored, their normal look evaluated, a normal examination carried out, and a complete neurological examination carried out as half of their bodily examination. The affected person’s scalp is palpated for any swellings or tenderness, the ipsilateral temporal artery is palpated, and the temporomandibular joints are palpated for any tenderness or crepitance because the affected person opens and closes their mouth. All of these examinations are carried out concurrently. Inspecting the realm across the eye for any indicators of conjunctival injection, corresponding to flushing, lacrimation, or bleeding. Along with evaluating the visible fields, the pupils’ sizes, responses to gentle, extraocular actions, and different traits are examined. It is very important conduct a fundus examination to search for papilledema and spontaneous retinal venous pulsations. The oropharynx needs to be examined for any indicators of swelling, and the affected person’s tooth needs to be palpated to detect any sensitivity. Flexion of the neck is carried out to test for any indicators of stiffness or discomfort, and palpation of the cervical backbone is finished to test for any indicators of tenderness.

The diagnostic imaging workup for headaches is essential in figuring out whether or not or not the affected person has bleeding within the mind or different abnormalities within the mind, as said by Filler et al. (2019, February). Laboratory exams will not be vital for almost all of sufferers who current with headache; nevertheless, exams are vital for the analysis of sure situations that current with headache in addition to these which might be emergent. Neuroimaging research, corresponding to a head CT scan and an MRI, are sometimes carried out on sufferers who’re affected by headaches. The lumbar puncture and CSF Assessment, the erythrocyte sedimentation price take a look at, and the total blood rely are additionally essential exams. These exams will be utilized to reach at an correct analysis of a main headache or a kind of secondary headache in addition to the underlying trigger of the secondary headache.

Discover a minimum of 5 completely different situations that may very well be related to the affected person’s analysis so that a differential analysis will be carried out.
A sinus headache is characterised by a urgent sensation across the eyes, cheek, and brow, as said by Hutchinson (2016).

Migraine headache is a kind of headache situation through which the affected person suffers from extreme headaches that come and go in waves.

Cluster headaches are the most typical sort of headache dysfunction which might be related to trigeminal autonomic cephalgia. Cluster headaches are commonest in younger males.

Pressure headaches are characterised by an absence of related signs, which leads medical professionals to discuss with them as “featureless headaches.” Though stress headaches happen in episodes, they not often intrude with day-to-day actions.

Idiopathic stabbing headache is a kind of headache that’s characterised by ache that’s sharp, temporary, however extreme, and it could actually happen anyplace within the head. This sort of headache will be fairly debilitating.

References
Gregory, J. (2019). Use of ache scales and observational ache Assessment instruments in hospital settings. Nursing Normal. doi, 10.

Lee, V. M. E., Ang, L. L., Quickly, D. T. L., Ong, J. J. Y., & Loh, V. W. Ok. (2018). The grownup affected person with headache. Singapore medical journal, 59(eight), 399.

Hutchinson, S. (2016). Sinus headaches.

Filler, L., Akhter, M., & Nimlos, P. (2019, February). Analysis and administration of the emergency division headache. In Seminars in neurology (Vol. 39, No. 01, pp. zero20-026). Thieme Medical Publishers. CASE STUDY: A 20-year-old male complains of experiencing intermittent headaches.

Grading Standards

To entry your rubric:

Week 9 Project 1 Rubric

Test Your Project Draft for Authenticity

To test your Project draft for authenticity:

Submit your Week 9 Project 1 draft and evaluate the originality report.

Submit Your Project by Day 6 of Week 9

Episodic/Centered SOAP Observe Template
Affected person Info:

Initials, Age, Intercourse, Race

CC (chief grievance) a BRIEF assertion figuring out why the affected person is right here – within the affected person’s personal phrases – for example “headache”, NOT “unhealthy headache for three days”.

HPI: That is the symptom Assessment part of your be aware. Thorough documentation on this part is crucial for affected person care, coding, and billing Assessment. Paint an image of what’s unsuitable with the affected person. Use LOCATES Mnemonic to finish your HPI. It’s essential to begin EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You need to embrace the seven attributes of every principal symptom in paragraph type not an inventory. If the CC was “headache”, the LOCATES for the HPI may appear like the next instance: CASE STUDY: A 20-year-old male complains of experiencing intermittent headaches.

Location: head

Onset: three days in the past

Character: pounding, strain across the eyes and temples

Related indicators and signs: nausea, vomiting, photophobia, phonophobia

Timing: after being on the pc all day at work

Exacerbating/ relieving elements: gentle bothers eyes, Aleve makes it tolerable however not fully higher

Severity: 7/10 ache scale

Present Medicines: embrace dosage, frequency, size of time used and purpose to be used; additionally embrace OTC or homeopathic merchandise.

Allergic reactions: embrace remedy, meals, and environmental allergic reactions individually (an outline of what the allergy is ie angioedema, anaphylaxis, and so forth. This may Help decide a real response vs intolerance).

PMHx: embrace immunization standing (be aware date of final tetanus for all adults), previous main sicknesses and surgical procedures. Relying on the CC, extra information is typically wanted

Soc Hx: embrace occupation and main hobbies, household standing, tobacco & alcohol use (earlier and present use), some other pertinent information. At all times add some well being promo Question Assignment right here – corresponding to whether or not they use seat belts on a regular basis or whether or not they have working smoke detectors in the home, residing setting, textual content/mobile phone use whereas driving, and help system.

Fam Hx: sicknesses with attainable genetic predisposition, contagious or power sicknesses. Cause for demise of any deceased first diploma family needs to be included. Embrace dad and mom, grandparents, siblings, and kids. Embrace grandchildren if pertinent.

ROS: cowl all physique programs which will allow you to embrace or rule out a differential analysis It’s best to checklist every system as follows: Common: Head: EENT: and so forth. It’s best to checklist these in bullet format and doc the programs so as from head to toe.

Instance of Full ROS:

GENERAL: No weight reduction, fever, chills, weak point or fatigue.

HEENT: Eyes: No visible loss, blurred imaginative and prescient, double imaginative and prescient or yellow sclerae. Ears, Nostril, Throat: No listening to loss, sneezing, congestion, runny nostril or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest ache, chest strain or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No belly ache or blood.

GENITOURINARY: Burning on urination. Being pregnant. Final menstrual interval, MM/DD/YYYY.

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

MUSCULOSKELETAL: No muscle, again ache, joint ache or stiffness.

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlarged nodes. No historical past of splenectomy.

PSYCHIATRIC: No historical past of melancholy or nervousness.

ENDOCRINOLOGIC: No stories of sweating, chilly or warmth intolerance. No polyuria or polydipsia.

ALLERGIES: No historical past of bronchial asthma, hives, eczema or rhinitis.

O.

Bodily examination: From head-to-toe, embrace what you see, hear, and really feel when doing all your bodily examination. You solely want to look at the programs which might be pertinent to the CC, HPI, and Historical past. Don’t use “WNL” or “regular.” You need to describe what you see. At all times doc in head to toe format i.e. Common: Head: EENT: and so forth.

Diagnostic outcomes: Embrace any labs, x-rays, or different diagnostics which might be wanted to develop the differential diagnoses (help with evidenced and pointers)

A.

Differential Diagnoses (checklist a minimal of three differential diagnoses).Your main or presumptive analysis needs to be on the high of the checklist. For every analysis, present supportive documentation with proof primarily based pointers.

This part isn’t required for the assignments on this course (NURS 6512) however will probably be required for future programs.

References

You’re required to incorporate a minimum of three proof primarily based peer-reviewed journal articles or evidenced primarily based pointers which pertains to this case to help your diagnostics and differentials diagnoses. You’ll want to use appropriate APA sixth version formatting.

Studying Sources – CASE STUDY: A 20-year-old male complains of experiencing intermittent headaches.

Required Readings (click on to develop/scale back)

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s information to bodily examination: An interprofessional method (ninth ed.). St. Louis, MO: Elsevier Mosby.

Chapter 7, “Psychological Standing”This chapter revolves across the psychological standing analysis of a person’s general cognitive state. The chapter features a checklist of psychological abnormalities and their signs.
·Chapter 23, “Neurologic System”The authors of this chapter discover the anatomy and physiology of the neurologic system. The authors additionally describe neurological examinations and potential findings.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Superior well being Assessment and scientific analysis in main care (sixth ed.). St. Louis, MO: Elsevier Mosby.

Credit score Line: Superior Well being Assessment and Medical Prognosis in Main Care, sixth Version by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby through the Copyright Clearance Middle.

Chapter four, “Affective Adjustments”
This chapter outlines establish the potential trigger of affective adjustments in a affected person. The authors present a prompt method to the analysis of this sort of change, and so they embrace particular instruments that can be utilized as half of the analysis.

Chapter 9, “Confusion in Older Adults”
This chapter focuses on causes of confusion in older adults, with an emphasis on dementia. The authors embrace prompt questions for taking a targeted historical past in addition to what to search for in a bodily examination.

Chapter 13, “Dizziness”
Dizziness generally is a symptom of many underlying situations. This chapter outlines the inquiries to ask a affected person in taking a targeted historical past and completely different exams to make use of in a bodily examination.

Chapter 19, “Headache”
The main focus of this chapter is the identification of the causes of headaches. Step one is to make sure that the headache isn’t a life-threatening situation. The authors give recommendations for taking an intensive historical past and performing a bodily examination.

Chapter 31, “Sleep Issues”
On this chapter, the authors spotlight the primary causes of sleep issues. Additionally they present attainable questions to make use of in taking the affected person’s historical past, issues to search for when performing a bodily examination, and attainable laboratory and diagnostic research that could be helpful in making the analysis.

Sullivan, D. D. (2019). Information to scientific documentation (third ed.). Philadelphia, PA: F. A. Davis.

Chapter 2, “The Complete Historical past and Bodily Examination” (“Cranial Nerves and Their Perform” and “Grading Reflexes”) (Beforehand learn in Weeks 1, 2, three, and 5)
Observe: Obtain the Bodily Examination Goal Information Guidelines to make use of as you full the Complete (Head-to-Toe) Bodily Assessment task.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Bodily examination goal information guidelines. In Mosby’s information to bodily examination (seventh ed.). St. Louis, MO: Elsevier Mosby.

Credit score Line: Mosby’s Information to Bodily Examination, seventh Version by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier through the Copyright Clearance Middle.

Observe: Obtain and evaluate the Pupil Checklists and Key Factors to make use of throughout your follow neurological examination.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Pupil guidelines. In Seidel’s information to bodily examination: An interprofessional method (ninth ed.). St. Louis, MO: Elsevier Mosby.

Credit score Line: Seidel’s Information to Bodily Examination, ninth Version by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Well being Sciences. Reprinted by permission of Elsevier Well being Sciences through the Copyright Clearance Middle.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Key factors. In Seidel’s information to bodily examination: An interprofessional method (ninth ed.). St. Louis, MO: Elsevier Mosby.

Credit score Line: Seidel’s Information to Bodily Examination, ninth Version by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Well being Sciences. Reprinted by permission of Elsevier Well being Sciences through the Copyright Clearance Middle.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Psychological standing: Pupil guidelines. In Seidel’s information to bodily examination: An interprofessional method (ninth ed.). St. Louis, MO: Elsevier Mosby.

Credit score Line: Seidel’s Information to Bodily Examination, ninth Version by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Well being Sciences. Reprinted by permission of Elsevier Well being Sciences through the Copyright Clearance Middle.

Bearden , S. T., & Nay, L. B. (2011). Utility of EEG in differential analysis of adults with unexplained acute alteration of psychological standing. American Journal of Electroneurodiagnostic Know-how, 51(2), 92–104.

This text critiques the use of electrocenographs (EEG) to help in differential diagnoses. The authors present differential diagnostic situations through which the EEG was helpful.

Athilingam, P ., Visovsky, C., & Elliott, A. F. (2015). Cognitive screening in individuals with power illnesses in main care: Challenges and suggestions for follow. American Journal of Alzheimer’s Illness & Different Dementias, 30(6), 547–558. doi:10.1177/1533317515577127

Sinclair , A. J., Gadsby, R., Hillson, R., Forbes, A., & Bayer, A. J. (2013). Transient report: Use of the Mini-Cog as a screening device for cognitive impairment in diabetes in main care. Diabetes Analysis and Medical Observe, 100(1), e23–e25. doi:10.1016/j.diabres.2013.01.zero01

Roalf, D. R., Moberg, P. J., Xei, S. X., Wolk, D. A., Moelter, S. T., & Arnold, S. E. (2013). Comparative accuracies of two frequent screening devices for classification of Alzheimer’s illness, delicate cognitive impairment, and wholesome growing old. Alzheimer’s & Dementia, 9(5), 529–537. doi:10.1016/j.jalz.2012.10.zero01. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036230/

Shadow Well being Help and Orientation Sources
Use the next sources to information you thru your Shadow Well being orientation in addition to different help sources:

Frey, C. [Chris Frey]. (2015, September four). Pupil orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Shadow Well being. (n.d.). Shadow Well being Help desk. Retrieved from https://help.shadowhealth.com/hc/en-us

Doc: Shadow Well being. (2014). Helpful ideas and tips (Model 2) (PDF)

Doc: Pupil Acknowledgement Kind (Phrase doc)

Observe: You’ll signal and date this type every time you full your DCE Project in Shadow Well being to acknowledge your dedication to Walden College’s Code of Conduct.

Doc: DCE (Shadow Well being) Documentation Template for Complete (Head-to-Toe) Bodily Assessment (Phrase doc)

Use this template to finish your Project three for this week.

Non-obligatory Sources – CASE STUDY: A 20-year-old male complains of experiencing intermittent headaches.
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

Chapter 14, “The Neurologic Examination” (pp. 683–765)This chapter offers an outline of the nervous system. The authors additionally clarify the fundamentals of neurological exams.
Chapter 15, “Psychological Standing, Psychiatric, and Social Assessments” (pp. 766–786)On this chapter, the authors present an inventory of frequent psychiatric syndromes. The authors additionally clarify the psychological, psychiatric, and social analysis course of.
Mahlknecht, P., Hotter, A., Hussl, A., Esterhammer, R., Schockey, M., & Seppi, Ok. (2010). Significance of MRI in analysis and differential analysis of Parkinson’s illness. Neurodegenerative Ailments, 7(5), 300–318. CASE STUDY: A 20-year-old male complains of experiencing intermittent headaches.

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