ASSESSING NEUROLOGICAL SYMPTOMS

48-year-old male with a history of diabetes mellitus type 2 complains of not being able to feel his toes in the left foot. He also complains of numbness in the heel of the right foot and a tingling sensation.

1.Consider what history would be necessary to collect from the patient in this case study
2.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?
3.Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
4.Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in this case study to which you were assigned using the episodic/focused note template.
.Provide evidence from the literature to support diagnostic tests that would be appropriate for the case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
instructions
To create a focused/episodic note, you must make up information for all aspects.
For example, your HPI should capture all aspects of the LOCATES mnemonic. Medical conditions listed for the past medical history should reflect the year of the diagnosis – not age. Calculate the year of the diagnosis. How is the condition managed? There are four categories for allergies – food, drugs, environmental, and latex. Seasonal is not a fifth category. It should be listed under environmental. Personal/Social, Sexual/Reproductive, and Health Maintenance should be robust and written in narrative format.

case study

A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.

ith 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 Assignment

Use 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.