NRNP 6531 Week 10 Assignment 1; Neurological HPI and Plan
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Week 10 Assignment 1: Neurological HPI & Plan
Patient: N.A., 45 y/o Caucasian Female.
Subjective:
CC: Fatigue, right arm weakness, and decreased vision
HPI: N. A. is a 45 y/o Caucasian female presenting today with generalized fatigue and right arm weakness for the last 2 months. She reports the fatigue and arm weakness are constant, and rates it at 6/10. She was seen in the office two months ago for the same symptoms. She was instructed to modify her body mechanics and to use the left arm more to relieve symptoms in her right arm. She states her arm weakness was improving after trying the vitamins and job modifications that were suggested during the last appointment, but a couple of days ago the arm started feeling weak again. She reports dropping things, numbness and tingling of the right arm and hand. She reports having tried aspirin, but it doesn't help. Patient denies previous injury or incident associated with the arm and hand weakness. Denies improvement of her fatigue after sleeping, and reports feeling rested after sleeping. Denies sleep disturbances. Denies problems with all other extremities, denies pain anywhere in the body. She reports that her fatigue has worsened somewhat since her father suffered the stroke and she is helping her mother more. She reports decreased vision in both eyes, the left more than the right. She reports having trouble driving, and states she needs glasses for driving. She reports her decreased vision has gradually worsened over time. She reports having double vision once 2 months ago but after taking a nap it went away. Denies double vision since that one episode. Denies loss of vision. Denies eye pain, flashing lights, and headaches........ Continue
