Week 9: Assessment of Cognition and the Neurologic System
A 63-year-old woman comes to your office because she’s been forgetting things…a young mother comes in concerned because her baby fails to make eye contact and is unresponsive to touch…a teenager comes in and a parent complains that the teen obsessively washes his hands.
An array of neurological conditions could be causing the above symptoms. When assessing the neurologic system, it is vital to formulate an accurate diagnosis as early as possible to prevent continued damage and deterioration of a patient’s quality of life.
This week, you will explore methods for assessing the cognition and the neurologic system.
Learning Objectives
Students will:
- Evaluate abnormal neurological symptoms
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for cognition and the neurologic system
- Assess health conditions based on a head-to-toe physical examination
Learning Resources
Required Readings
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.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
- Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5)
Note: Download the Physical Examination Objective Data Checklist to use as you complete the Comprehensive (Head-to-Toe) Physical Assessment assignment.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical examination objective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Mosby’s Guide to Physical Examination, 7th Edition 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 via the Copyright Clearance Center.
Note: Download and review the Student Checklists and Key Points to use during your practice neurological examination.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Mental status: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Bearden , S. T., & Nay, L. B. (2011). Utility of EEG in differential diagnosis of adults with unexplained acute alteration of mental status. American Journal of Electroneurodiagnostic Technology, 51(2), 92–104.
This article reviews the use of electrocenographs (EEG) to assist in differential diagnoses. The authors provide differential diagnostic scenarios in which the EEG was useful.
Athilingam, P ., Visovsky, C., & Elliott, A. F. (2015). Cognitive screening in persons with chronic diseases in primary care: Challenges and recommendations for practice. American Journal of Alzheimer’s Disease & Other Dementias, 30(6), 547–558. doi:10.1177/1533317515577127
Sinclair , A. J., Gadsby, R., Hillson, R., Forbes, A., & Bayer, A. J. (2013). Brief report: Use of the Mini-Cog as a screening tool for cognitive impairment in diabetes in primary care. Diabetes Research and Clinical Practice, 100(1), e23–e25. doi:10.1016/j.diabres.2013.01.001
Roalf, D. R., Moberg, P. J., Xei, S. X., Wolk, D. A., Moelter, S. T., & Arnold, S. E. (2013). Comparative accuracies of two common screening instruments for classification of Alzheimer’s disease, mild cognitive impairment, and healthy aging. Alzheimer’s & Dementia, 9(5), 529–537. doi:10.1016/j.jalz.2012.10.001. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036230/
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:
Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY
Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us
Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)
Document: Student Acknowledgement Form (Word document)
Note: You will sign and date this form each time you complete your DCE Assignment in Shadow Health to acknowledge your commitment to Walden University’s Code of Conduct.
Document: DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment (Word document)
Use this template to complete your Assignment 3 for this week.
Optional Resources
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 provides an overview of the nervous system. The authors also explain the basics of neurological exams.
· Chapter 15, “Mental Status, Psychiatric, and Social Evaluations” (pp. 766–786)
In this chapter, the authors provide a list of common psychiatric syndromes. The authors also explain the mental, psychiatric, and social evaluation process.
Mahlknecht, P., Hotter, A., Hussl, A., Esterhammer, R., Schockey, M., & Seppi, K. (2010). Significance of MRI in diagnosis and differential diagnosis of Parkinson’s disease. Neurodegenerative Diseases, 7(5), 300–318.
Required Media
Neurologic System – Week 9 (16m)
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 7 and 23 that relate to the assessment of cognition and the neurologic system. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/
Assignment 1: Case Study Assignment: 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 living. 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 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.
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.
Week 9 Assignment Sample Paper
NURS 6512 Week 9 Assignment: Case Study Assignment: Assessing Neurological Symptoms
Episodic/Focused SOAP Note Template
Patient Information:
Initials: GM Age: 33 y.o Sex: Female Race: African American
SUBJECTIVE DATA:
Chief complaint: She states, I have a drooping on the right side of my face
HPI: G.M is a 33-year-old African American woman who presents in the clinic complaining of a right-sided facial drooping. She states that she noted it after waking up in the morning. She further says that her right eye has been watering continuously, and she cannot stop drooling out of her mouths side right. She has no pain.
Current Medications: Multivitamin every day, Tylenol 325mg-2 PO every 4 hours as required, Ibuprofen 200mg-2 PO as required, Valtrex 500mg – PO 3 x every day
Allergies: NKDA
Past Medical History: Asthma when she was a child and genital herpes some years back.
Past Surgical History: Cholecystectomy in the year 2000 and extraction of wisdom teeth while young
Social History: She takes alcohol rarely; denies making illicit drug use or smoking.
Family History: She has one brother with hypertension and a daughter who is 13years old healthy and living at home
Immunizations History: Her vaccinations are up to date. She had a flu vaccine lastly on February and had tetanus shot the previous two years when she had injured her arm on a metal piece.
REVIEW OF SYSTEMS
General: Pleasant 33-year-old woman posing in a chair talking reasonably fast. She appears very worried and is anxious; she has had a stroke. She is a good historian.
HEENT: No variations in hearing or vision; she had an eye test previous two years. GL stated no glaucoma, floaters, diplopia, photophobia, or extreme tearing history. She never before had any current infections of the ear, release, or tinnitus from her ears. Intact smell sense. GL has had no epistaxis episodes. She has no nasal polyp’s history or current sinus infection. Her previous dental examination was three years. She denied lesions, ulceration, bleeding gums, gingivitis, and she has no dental applications. No trouble swallowing or eating.
Throat: No sneezing, loss of hearing, congestion, sore throat, or runny nose.
Skin: No itching or rash.
Cardiovascular: No chest distress, palpitations murmurs, no history of arrhythmias, paroxysmal nocturnal dyspnea, orthopnea, claudication, or edema history.
Respiratory: Denied hemoptysis and has no trouble breathing at rest.
Gastrointestinal: No nausea. No abdomen ache, no variations in the bowel pattern.
Genitourinary: No variation in her urinary form, incontinence, or dysuria. GL is heterosexual. She has consistent menses. Human Papilloma Virus is positive and is not sexually active presently.
Neurological: No episodes of syncopal or dizziness, headaches, and paresthesia. No variation in the original patterns; no abnormal movements or twitches; no gait disorder history or difficulties with coordination. No seizure or falls history.
Musculoskeletal: No myalgia or arthralgia, gout or restraint in her motion range by the report, no arthritis. No history of fractures or trauma.
Hematologic: No anemia, bleeding, or bruising.
Lymphatic: No itching or staining, rashes. G.I use lotion to avert dry skin. No skin cancer history or removal of the lesion. She has no blood loss conditions, clotting problems, or transfusions history.
Psychiatric: No depression or anxiety history. No delusions sleep disruption or a history of mental condition. Denied homicidal or suicidal history
Endocrine: No signs of endocrine or hormone therapies
Allergies: She has no recognized immune shortages. Had an HIV test lastly the previous two years
OBJECTIVE DATA
Physical Exam:
Vital signs: B/P: 120/80, RR 18, T 98.8 orally; Wt. 115, Ht: 5’2 and BMI 21
General: Nothing Abnormal Detected, appears to be contented
HEENT: EOMI, PERRLA, clear oronasopharynx; extreme tearing right eye; faces right side drooping as well as mild nasolabial fold destruction
Neck: No JVD or legally and bruit
Chest: CTA AP&L
Heart: RRR with no murmurs, gallop or rub; pulsations, two bilat pedal, and two radial
Abdomen: benign, no organomegaly; no suprapubic sensitivity; no reverberation
Genital/Rectal: Peripheral genitalia complete no cervical wave sensitivity, no adnexal crowds.
Musculoskeletal: Asymmetric muscle growth. All joints are ordinary.
Neuro: CN II – XII grossly complete, Deep Tendon Reflex perfect for paresis on the faces right side and for trouble making facial languages.
Skin/Lymph Nodes: No clubbing, edema, or cyanosis; no tangible nodes
History essential to obtain from the patient
If the patient has any pain, burning, loss of feeling anywhere in her body if she is having problems with her vision. History of her recent illness, history of stroke in her family, her past medical history, surgeries, and medications would be necessary as well.
Additional Physical Examinations:
Performing an original Cincinnati Stroke Scale and Glasgow Coma Scale to evaluate mentation and stroke possibility, thoroughly inspect her face, head, and neck, neurovascular valuation in all the 4 extremities, swallow assessment, and cost of her facial cranial nerve function through raising her eyebrows, squeezing her eyes shut, puff out her cheeks, smile and purse her lips and blow out. This will indicate more of Bell’s palsy.
Additional Diagnostic Testing
In an outpatient situation, I would reach out for 911 for transport to an emergency unit for further assessment, and insist on a head CT to rule out a severe stroke. I would then consider extra electrophysiological testing on a cranial facial nerve in case an acute stroke was ruled out to find if the facial nerve is the culprit.
ASSESSMENT:
- Priority Diagnosis: Facial Nerve Paralysis (Bell’s Palsy)-Classically presents as one-sided upper and lower facial paralysis with reduced eyelid cessation to the affected side and trouble tearing, sensory variations to the affected side occasionally noted, and flattened forehead with incapability of creating creases whenever raising eyebrows on affected side (Eviston, Croxson, Kennedy, Hadlock & Krishnan 2015).
Differential Diagnoses
- Stroke: Frequently present with the facial drooping, but affects one side of body Writing, (Mozaffarian, Benjamin, Go, Arnett, Blaha & Fullerton 2016). If a patient can raise their eyebrows usually and correspondingly, but the inferior part of their face remains paralyzed, the health care provider will need to rule out stroke
- Tetanus: Cephalic tetanus, although uncommon, generally occurs after an ear infection or trauma, and presents with cranial nerve palsy, which might be localized
- Mastoiditis: This is a bacterial infection of the temporal bone and presents with otalgia, otorrhea, tenderness, swelling like symptoms, and facial palsy is an intertemporal problem (Mather, Yates, Powell & Zammit-Maempel 2019).
- Lyme disease: A disease triggered by a bacteria that ticks may carry. Lyme disease causes Bell’s palsy since advanced signs of Lyme illness can affect the nervous system.
- Guillain-Barre Syndrome: Generally begins as weakness and paresthesias weakness and gradually ascending, the symptoms include facial droop, dysphagia, diplopia, dysarthria, and pupillary disorders (Willison, Jacobs & van Doorn 2016).
References
Eviston, T. J., Croxson, G. R., Kennedy, P. G., Hadlock, T., & Krishnan, A. V. (2015). Bell’s palsy: etiology, clinical features, and multidisciplinary care. J Neurol Neurosurg Psychiatry, 86(12), 1356-1361.
Mather, M. W., Yates, P. D., Powell, J., & Zammit-Maempel, I. (2019). Radiology of acute mastoiditis and its complications: a pictorial review and interpretation checklist. The Journal of Laryngology & Otology, 1-6.
Willison, H. J., Jacobs, B. C., & van Doorn, P. A. (2016). Guillain-barre syndrome. The Lancet, 388(10045), 717-727.
Writing, G. M., Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., … & Fullerton, H. J. (2016). Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation, 133(4), e38.
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.
By Day 6 of Week 9
Submit your Assignment.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
- Please save your Assignment using the naming convention “WK9Assgn1+last name+first initial.(extension)” as the name.
- Click the Week 9 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
- Click the Week 9 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
- Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK9Assgn1+last name+first initial.(extension)” and click Open.
- If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
- Click on the Submit button to complete your submission.
Grading Criteria
To access your rubric:
Week 9 Assignment 1 Rubric
Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:
Submit your Week 9 Assignment 1 draft and review the originality report.
Submit Your Assignment by Day 6 of Week 9
To participate in this Assignment:
Week 9 Assignment 1
Assignment 2: Lab Assignment: Practice Assessment: Neurological Examination
Short of opening a patient’s cranium or requesting a brain scan, what can an advanced practice nurse do to determine the cause of neurological symptoms? A multitude of techniques can be used to generate a neurological diagnosis.
In preparation for the Comprehensive (Head-to-Toe) Physical Assessment due this week, it is recommended that you practice performing a neurological examination.
Note: This is a practice physical assessment.
To Prepare
- Arrange an appropriate time and setting with a volunteer “patient” to perform a neurological examination.
- Download and review the Neurological Checklist provided in this week’s Learning Resources as well as review Seidel’s Guide to Physical Examination online media.
The Lab Assignment
Complete the following in Shadow Health:
- Neurological (Practice)
Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
Throughout this course, you were encouraged to practice conducting various physical assessments on multiple areas of the body, ranging from the head to the toes. Each of these assessments, however, was conducted independently of one another. For this DCE Assignment, you connect the knowledge and skills you gained from each individual assessment to perform a comprehensive head-to-toe physical examination in your Digital Clinical Experience.
To Prepare
- Review this week’s Learning Resources, and download and review the Physical Examination Objective Data Checklist as well as the Student Checklists and Key Points documents related to neurologic system and mental status.
- Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.
- Review the DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
- Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
- Review the Week 9 DCE Comprehensive Physical Assessment Rubric provided in the Assignment submission area for details on completing the Assessment in Shadow Health.
Note: There are 2 parts to this assignment – the lab pass and the documentation. You must achieve a total score of 80% in order to pass this assignment. Carefully review the rubric and video presentation in order to fully understand the requirements of this assignment.
DCE Comprehensive Physical Assessment:
Complete the following in Shadow Health:
- Episodic/Focused Note for Comprehensive Physical Assessment of Tina Jones (180 minutes)
Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 9 Day 7 deadline.
Submission and Grading Information
By Day 7 of Week 9
- Complete your Comprehensive (Head-to-Toe) Physical Assessment DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.
- Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding Assignment in Blackboard for your faculty review.
- (Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass
- Once you submit your Documentation Notes to Shadow Health, make sure to copy and paste the same Documentation Notes into your Assignment submission link below.
- Download, sign, date, and submit your Student Acknowledgement Form found in the Learning Resources for this week.
- Note: You must pass this assignment with a minimum score of 80% in order to pass the class. Once submitted, there are not any opportunities to revise or repeat this assignment.
Grading Criteria
To access your rubric:
Week 9 Assignment 3 DCE Rubric
Submit Your Assignment by Day 7 of Week 9
To submit your Lab Pass:
Week 9 Lab Pass
To sumit this required part of the Assignment:
Week 9 Documentation Notes for Assignment 3
To Submit your Student Acknowledgement Form:
Submit your Week 9 Assignment 3 DCE Student Acknowledgement Form
What’s Coming Up in Week 10?
Next week, you will examine how to assess problems with the breasts, genitalia, rectum, and prostate while making the patient feel safe, listened to, and cared about using a non-invasive approach. Once again, you will use a SOAP note format to complete your Lab Assignment for this week.
Week 10 Required Media
Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Discussion. There are several videos of various lengths. Please plan ahead to ensure you have time to view these media programs to complete your Lab Assignment on time.
Next Week
To go to the next week:
Week 10
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