Patient’s Diagnosed with Multiple Sclerosis Case Study
Important Instruction about the Assignment
· You will then formulate your differential diagnoses list, develop a plan of care, and submit a written clinic note documenting your care of this patient. Your differential diagnoses list should consist of 4 diagnoses, including 1 of which is your final diagnosis.
· Please briefly describe your rationale and reasoning for why you would include or rule out a diagnosis in your working diagnosis list. Provide 6 research nursing and medical references for your rationale.
· The paper should always have an introductory statement that explains what the paper will entail.
· Remember to include a cover page and use the most recent update APA formatting for references.
· Refer to the SOAP NOTE TEMPLATE for details on how this assignment will be graded.
· For this paper, you must provide 12-15 pages well written evidence-based research paper according to the rubric guidelines, follow the APA format formatting for references and support your paper with at least 5 to 7 nursing or medical evidence-based research articles not older than 7 yrs.
Please take time to read and review it, if the paper is not up a master’s degree level standard, I will not accept the work. I just want to be clear about that before I assigned it to anyone. This is an advanced degree work that requires a very strong writer with a background and experience in Nursing and Medical field and a very well-developed English and written expertise.
Patient’s Headache Case Study B
The patient is 42 years old female with complaint of urinary incontinence. She reports having two accidental urination within the last 24 hours. She also reported feeling extra tired and fatigue that started 6 months ago. she further explained that her lower extremities have been feeling week and tired which started 3 months ago without any acute cause. Patient has also be experiencing sporadic blurred vision that occurred 3 months ago. Patient denied any pain during urination, denies any burning sensation, or Vaginal odor during urination. Patient has history of car accident that occurred 10 years ago which left her with numbness and tingling sensation in her right leg however she stated she has not experienced any paresthesia in years. As stated above, she does experience unsteady gait and complete loss of control in her lower extremities that sometimes last for few seconds. She said sleeping at night does not eliminate the fatigue feeling. Clinical assessment and physical finding show bilateral lower extremities weakness correlated with neurological disorder or central nervous system problems
Patient reports “I had two accidents yesterday. I accidentally peed on myself. I feel really embarrassed about it.” She describes feeling extra tired over the last few months (6 months to be exact) in addition to the patient Problem statement.
Reliability and Source of History:
The patient is alert and oriented and able to answer most of the questions.
Subjective and Objective Data.
Hint 1 (Patient primary diagnoses is Multiple sclerosis) other potential diagnoses are:
· Urinary Tract Infection
· Vitamin B deficiency
· ALS (Amyotrophic Lateral sclerosis)
Hint 2 (patient treatment plan which should include the up-to-date treatment for Multiple Sclerosis
Patient lab should include all below and please explain the rationale for these labs with references to support it.
· MRI of the brain and spine
· CBC with BMP (Especially to test for vitamin B12 deficiency)
· EMG (electromyogram)
· Cerebrospinal fluid analysis (CSF)
· ANA (Antinuclear Antibody Test)
· CSF (Cerebrospinal fluid analysis)
Typing Template for SOAP notes:
This is the differential diagnosis section. List FOUR differential/working diagnoses. One of this will be your final diagnosis. For EACH of your diagnoses list a brief rationale indicating why this diagnosis should be considered or not considered as the final diagnosis. Include references used to guide your thinking.
1. Multiple Sclerosis (Main Diagnosis)
2. Urinary Tract Infection
4. Vitamin B deficiency
5. ALS (Amyotrophic Lateral sclerosis)
All plans until you graduate contain the following elements. If an item does not apply to the particular situation, please indicate- not applicable or not needed at this time. If it’s not indicated it is assumed to not have been addressed.
Pharmacology Medications both prescription and OTC go here. Write out your prescription meds just like a prescription.
Non-Pharmacology What non-pharmacologic interventions do you recommend for your patient?
Diagnostics Are there any lab tests, radiology or other diagnostics you would like to order? Remember to think primary care. No troponins or bedside stat echos in the office.
Consults / Referrals Would you like to phone a friend? Should they follow up with a specialist for additional or further care?
Patient Education What important information do you need to make certain they know? Don’t forget about serious medication interactions or OCP.
Follow Up Think about how much leeway you want to give this patient before someone lays eyes on them again? One week? Two? What should they do if they experience new or worsening symptoms?