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 Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the Episodic/Focused SOAP Note format, rather than the traditional narrative style Discussion posting format.  Assessing Neurological Symptoms Case Study

Case 2: Numbness and Pain

A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools.
To prepare:

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.
Note: Before you submit your initial post, replace the subject line (\”Discussion – Week 9\”) with \”Review of Case Study ___.\” Fill in the
blank with the number of the case study you were assigned.
REFERENCES
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel\’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Chapter 5, “Mental Status” (64-78)
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 Electro neuro diagnostic Technology, 51(2), 92–104.

By Day 3
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in 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.

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Assessing Neurological Symptoms
Patient Information:
AB, 47-year-old African-American Female

SUBJECTIVE DATA:
CC (chief complaint): Pain in the right wrist, with tingling and numbness in the fingers
History of Present Illness (HPI): Mrs. AB, 47-year-old African-American female presented to the clinic with complaints about pain in her right wrist and tingling and numbness within the thumb, middle fingers, and the index finger. The patient reported that the pain onset was 2 weeks ago. She further reported that the pain makes it impossible for her to hold her hair-styling tools.
Medications: Progesterone 300 mg daily, Ibuprofen 500 mg TID for pain
Allergies: None
Past Medical History (PMH): Obesity
Past Surgical History (PSH): CS 2012
Sexual/Reproductive History: Sexually active
Personal/Social History: Does not smoke, does not take alcohol
Immunization History: All vaccinations up to date; pneumococcal vaccination in 2014, influenza vaccination 2018
Family History: Mother has depression and obesity, the father has type 2 diabetes
Lifestyle: The patient works 8 hours a day as a hairdresser from Monday to Saturday. She lives with her husband who is an engineer. She is a mother to two children who are grownups and working. Currently, she lives in her own home with her husband.

REVIEW OF SYSTEMS:
General: The patient appears overweight
HEENT: Wears reading glasses; no facial abnormality; denies blurred vision; hearing normal; no nasal congestion; normal tonsils; no sore throat.
Neck: Normal neck movement; thyroid glands normal
Breasts: No lump or mass; no pain
Respiratory: Normal air movement
Cardiovascular: Heartbeat normal; no murmurs; no palpitations
Gastrointestinal: The bowel sound is normal; no diarrhea
GU: Urinary pattern normal; genitalia normal
Musculoskeletal: Pain, tingling and numbness for the right fingers
Psychiatric: Sleep problems due to pain for the last 2 days
Neurological: Numbness or tingling of the right-hand fingers; no dizziness
Hematologic: No bleeding or bruises
Skin: Skin appears normal
Endocrine: Normal urinary pattern; no excess sweating
Allergic: None  Assessing Neurological Symptoms Case Study

OBJECTIVE DATA:
Physical Examination
Vital Signs: 18 breaths per minute, body temperature 36.8°C, Blood Pressure 120/80, weight 108 kgs
HEENT: Wears reading glasses; no facial abnormality; denies blurred vision; hearing normal; no nasal congestion; normal tonsils; no sore throat.
Neck: Normal neck movement; thyroid glands normal
Chest: Normal air movement; lungs clear
Heart: Heartbeat normal; no murmurs
Genital/Rectal: Rectal sphincter tone normal; normal genitalia; normal stool
Musculoskeletal: Pain, tingling and numbness for the right fingers
Neurological: Numbness or tingling of the right-hand fingers; no dizziness
Skin: Skin appears normal

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ASSESSMENT:
Diagnostic Tests
• Physical examination: This includes testing the feeling in the fingers as well as the muscle strength of the hand. It involves tapping on the nerve and wrist bending to identify the symptoms.
• Wrist-flexion test: The test involves pressing the backs of fingers and hands together while the wrists are flexed for about 1-2 minutes to test any tingling or numbness for the fingers (Burton et al, 2014).
• X-ray: An x-ray will rule out other causes of the patient’s pain such as fracture or arthritis
• Tinel’s Sign: The test involves pressing the median nerve on the wrist’s median nerve using a reflex hammer t test any tingling (Saint-Lary et al, 2015).

Differential Diagnosis
• Carpal Tunnel Syndrome: This is the first differential diagnosis for the patient. This is because a review of the patient’s symptom patterns indicates all symptoms of the syndrome especially because the little finger is not having any tingling and numbness because the median nerve does not provide sensation to the small finger (Yunoki et al, 2017).
• Cervical radiculopathy: This is the second differential diagnosis because the diagnosis is typified by numbness in the index finger and thumb only and also there is neck pain and the patient is not experiencing neck pain.
• De Quervain tenosynovitis: This is characterized by pain when the thumb/wrist is movement and commonly occurs within the two wrists. This is the third differential diagnosis because the pain is only in one hand (Akgun et al, 2014).
• Carpometacarpal arthritis of thumb: This is characterized by joint line pain and pain during movement. This is the fourth differential diagnosis because it warrants a radiologic finding and also the patient is experiencing pain on other fingers as well.
• Flexor carpi radialis tenosynovitis: This is the last differential diagnosis because this diagnosis is typified by tenderness near the thumb’s base and the patient is not manifesting any tenderness near the base of the thumb (Akgun et al, 2014).

References
Akgun H, Yucel M, Oz O & Demirkaya S. (2014). Differential diagnosis of carpal tunnel syndrome. Turk Neurosurg. 24(1), 150.
Burton C. Linda C & Davenport G. (2014). Diagnosing and managing carpal tunnel syndrome in primary care. Br J Gen Pract. 64(622), 262–263.
Saint-Lary O, Rebois A, Zakia M & Descatha A. (2015). Carpal Tunnel Syndrome: Primary Care and Occupational Factors. Front Med (Lausanne). 2(28).
Yunoki M, Kanda T, Suuki K, Uneda A, Rashita K & Yoshino K. (2017). Importance of Recognizing Carpal Tunnel Syndrome for Neurosurgeons: A Review. Neurol Med Chir (Tokyo). 57(4), 172–182.  Assessing Neurological Symptoms Case Study