Assessing Neurological Symptoms

Imagine not being able to form new memories. This is the reality patients with anterograde amnesia face. Although this form of amnesia is rare, it can result from severe brain trauma. Anterograde amnesia demonstrates just how impactful brain disorders can be to a patient’s quality of life. Accurately assessing neurological symptoms is a complex process that involves the analysis of many factors.In this Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.To PrepareBy 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.With regard to the case study you were assigned:Review this week’s Learning Resources, and consider the insights they provide about the case study.Consider what history would be necessary to collect from the patient in the case study you were assigned.Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.The Case Study AssignmentUse the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.BELOW IS THE CASE STUDY———————-CASE STUDY 1: Headaches (Students in Group C)A 40-year-old female presents with complaint of a headache for one week. Reports a “head cold” 3 weeks ago. Thought it was getting better, but sinus symptoms are back and even worse.Describes the headache is located across her forehead; feels like pressure behind my eyes and unable to breathe out of nose. Also feels mucus running down the back of throat. Pain sometimes severe (8/10) but with acetaminophen reduces to moderate (4/10) and occasionally mild (2/10). Occasional nonproductive cough. Feels feverish at times; noted frequent sneezing and no appetite. Bending over seems to make the headache worse. “Acetaminophen improves my headache, but doesn’t take it away.” Taking Sudafed HCL 120 mg every 12 hours, with some relief. Symptoms are worse in the morning – awakes with a headache. Ranges from 2/10 at its best to 8/10. Difficulty with concentrating at job and feels very tired.BELOW IS THE REQUIRED READING—————————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.Chapter 7, “Mental Status”This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms.-Chapter 23, “Neurologic System”The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings.Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.Chapter 4, “Affective Changes”This chapter outlines how to identify the potential cause of affective changes in a patient. The authors provide a suggested approach to the evaluation of this type of change, and they include specific tools that can be used as part of the diagnosis.Chapter 9, “Confusion in Older Adults”This chapter focuses on causes of confusion in older adults, with an emphasis on dementia. The authors include suggested questions for taking a focused history as well as what to look for in a physical examination.Chapter 13, “Dizziness”Dizziness can be a symptom of many underlying conditions. This chapter outlines the questions to ask a patient in taking a focused history and different tests to use in a physical examination.Chapter 19, “Headache”The focus of this chapter is the identification of the causes of headaches. The first step is to ensure that the headache is not a life-threatening condition. The authors give suggestions for taking a thorough history and performing a physical exam.Chapter 31, “Sleep Problems”In this chapter, the authors highlight the main causes of sleep problems. They also provide possible questions to use in taking the patient’s history, things to look for when performing a physical exam, and possible laboratory and diagnostic studies that might be useful in making the diagnosis. CORE SKILL: localizing the lesion. In neurology the question is not just “what is it?” but “WHERE is it?” — anatomy first, etiology second.
THE MEMORY SYSTEM (the prompt’s anterograde amnesia framing): ANTEROGRADE = cannot form NEW memories after the insult; RETROGRADE = cannot retrieve memories from BEFORE it. The structure is the HIPPOCAMPUS (bilateral medial temporal lobe) plus the mammillary bodies and dorsomedial thalamus (the Papez circuit). The canonical lesson is patient H.M. — bilateral medial temporal resection produced dense anterograde amnesia while PROCEDURAL memory (motor learning) and working memory remained intact, which is the evidence that memory is not one system. Know WERNICKE-KORSAKOFF: thiamine (B1) deficiency, classically alcohol-related; Wernicke’s triad = confusion + ophthalmoplegia + ataxia (and it is reversible, hence: give THIAMINE BEFORE GLUCOSE, since a glucose load without thiamine can precipitate it); Korsakoff = the chronic amnestic sequel with CONFABULATION. Also transient global amnesia, HSV encephalitis (temporal lobe predilection), and early Alzheimer’s (hippocampal atrophy first — hence anterograde memory loss as the earliest symptom).
THE NEURO EXAM — organize it and don’t skip domains: mental status, cranial nerves II–XII, motor (bulk, tone, strength 0–5), reflexes (0–4+, plus Babinski), sensory (light touch, pinprick, vibration, proprioception), cerebellar (finger-to-nose, heel-to-shin, rapid alternating movements, Romberg), gait.
THE SINGLE MOST USEFUL DISTINCTION: UPPER vs. LOWER MOTOR NEURON. UMN = weakness, HYPERreflexia, increased tone/spasticity, positive Babinski, no significant atrophy, no fasciculations. LMN = weakness, HYPOreflexia, decreased tone, atrophy, fasciculations. That one table localizes half of all neuro cases.
STROKE LOCALIZATION worth knowing: MCA (contralateral face/arm > leg weakness, aphasia if dominant hemisphere, neglect if non-dominant), ACA (contralateral leg > arm), PCA (visual field deficits). Cortical signs (aphasia, neglect) point to cortex; pure motor hemiparesis suggests a lacunar/internal capsule lesion.
FOR THE CASE: build 5 differentials, and for each state the anatomical location it would require plus the diagnostic test that would confirm or exclude it (CT vs. MRI vs. LP vs. EEG — and know WHY: non-contrast CT first in acute stroke to rule out hemorrhage before thrombolytics).

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