Neuroanatomy and Clinical Case Studies PDF

WELCOME TO NEUROANATOMY BIO336 Audrey Forbes-Cardinali, D.C. Mercyhurst University  N E U ROA N ATO M Y The study of the structures and organization of the nervous system. Why study it through clinical cases?  CLINICAL CASE STUDIES Case studies are...

WELCOME TO NEUROANATOMY BIO336 Audrey Forbes-Cardinali, D.C. Mercyhurst University  N E U ROA N ATO M Y The study of the structures and organization of the nervous system. Why study it through clinical cases?  CLINICAL CASE STUDIES Case studies are a ubiquitous part of medical education Useful in development of critical thinking and application of knowledge. Generally follow a specific pattern to ensure clear effective communication Used not only in education, but also serves as the basis for sharing information during rounds. Chief complaint Social and environmental history History of the present illness Medications and allergies Past medical history Physical exam Review of systems Laboratory data Family history Assessment and plan  CHIEF COMPLAINT A N D HISTORY OF THE PRESENT ILLNESS Chief Complaint (CC) This is a concise statement that includes the patient’s age, biologic sex and presenting problem Example: “The patient is a 42-year-old female presenting with hip pain after a fall down a flight of stairs.” History of the Present Illness (HPI) This is the complete history of the current medical problem. It should include Possible risk factors or causes of the current illness A chronological description of the development of the condition Any previous care for the condition Related medical conditions Pertinent negative information (symptoms or problems that are not present) to help rule out other pathologies.  PAST MEDICAL HISTORY A N D REVIEW OF SYSTEMS Past Medical History (PMH) Should include other, non-related medical conditions. Example: “The patient has a 6 year history of mild hypertension.” Review of Systems (ROS) A brief review of all medical systems Includes HEENT, Cardiopulmonary, GI, GU, OB?GYN, dermatologic, Neurologic, musculoskeletal, psychiatric, hematological, oncologic, rheumatological, endocrine, infectious diseases, etc. Example: “The patient has had asthma since the age of 12. She has 2 children (G2- P2-0-2) ages 6 and 8.”  FAMILY HISTORY, SOCIAL HISTORY A N D MEDICATIONS & ALLERGIES Family History (FHx) A brief synopsis of any illness in all immediate family members. Example: “Patient’s mother died at 71 of stroke, had hypertension. Father had myocardial infarction at 63, died at 78 of pneumonia. Brother, 47 years old, healthy. Two children, healthy.” Social and Environmental History (SocHx/EnvHx) This section should include the patient’s occupation, family situation, travel history, sexual history (if not covered in ROS), and other social habits. Example: “Electrical engineer. Married with two children. No recent travel. Denies ever smoking cigarettes or using drugs. Drinks 1–2 glasses of wine through the week.” Medications and Allergies This section should list all current medications (including vitamins, supplements or over- the-counter drugs), as well as any known general or drug allergies.  PHYSICAL EXAM The examination generally proceeds from head to toe and includes the following sections: General appearance—for example, “A diaphoretic man in clear discomfort.” Vital signs—temperature (T), pulse (P), blood pressure (BP), respiratory rate (R) HEENT (head, eyes, ears, nose, and throat) Abdomen Neck Extremities Back and spine Pulses Lymph nodes Neurologic Breasts Rectal Lungs Pelvic and genitalia Heart Dermatologic  LABORATORY DATA A N D ASSESSMENT & PLAN Laboratory Data This comprises all diagnostic tests (Blood work, CSF/urine tests, electrocardiogram, and radiological tests (chest X-rays, CT scans, etc.). Assessment and Plan This should begin with a 1 sentence summary and likely diagnosis. If the diagnosis is uncertain, a brief discussion can be included that should include a differential diagnosis.. The plan section immediately follows the assessment and is usually broken down into a list of problems and proposed interventions and diagnostic procedures.