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A 67-year-old man is brought to the office by his daughter who reports he has been experiencing increased forgetfulness. She provides examples of him misplacing his car keys multiple times and calling her for directions home after driving to the store. A focused SOAP note is to be created about the patient using the provided template. Differential diagnoses should be proposed and justified, and appropriate diagnostic tests identified based on evidence from literature.

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99 views2 pages

Attachment - 1 - 2023-04-27T072520.960

A 67-year-old man is brought to the office by his daughter who reports he has been experiencing increased forgetfulness. She provides examples of him misplacing his car keys multiple times and calling her for directions home after driving to the store. A focused SOAP note is to be created about the patient using the provided template. Differential diagnoses should be proposed and justified, and appropriate diagnostic tests identified based on evidence from literature.

Uploaded by

atrian
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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ASSESSING NEUROLOGICAL SYMPTOMS

CASE STUDY ASSIGNMENT: Forgetfulness

Asia brings her 67-year-old father into the office stating he is very forgetful. He has lost his car
keys several times. She also states he has driven to the store and called her asking for directions
to get back home. 

In at least FOUR (4) pages, Use the Episodic/Focused SOAP Template and create an
episodic/focused note about the patient in the case study above using the episodic/focused note
template provided.
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. 

 With regard to the case study you were assigned:

 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 attached. Remember that all Episodic/Focused
SOAP notes have specific data included in every patient case.
 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?
RESOURCES

 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.

o 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.
o Chapter 23, “Neurologic System”

 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.

o Chapter 4 – Affective changes


o Chapter 9 – Confusion in older Adults,
o Chapter 13 - Dizziness,
o Chapter 19 - Headache
o Chapter 31 - sleep problem)

 Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A.


Davis.
o Chapter 2, "The Comprehensive History and Physical Exam" ("Cranial Nerves and
Their Function" and "Grading Reflexes")

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