NURS 6512 – WEEK 3 IHUMAN CASE STUDY: A 45-YEAR-OLD FEMALE PRESENTING WITH ARM WEAKNESS – NEUROLOGICAL AND MUSCULOSKELETAL ASSESSMENT

NURS 6512 – WEEK 3 IHUMAN CASE STUDY: A
45-YEAR-OLD FEMALE PRESENTING WITH ARM
WEAKNESS – NEUROLOGICAL AND
MUSCULOSKELETAL ASSESSMENT

,PART 1: PATIENT BIO DATA & INITIAL DATA
GATHERING
Category Details

Name [To be specified in case]

,Category Details

Age 45 years old

Gender Female

Ethnicity [To be specified]

Height [To be specified]

Weight [To be specified]

BMI [To be calculated]

Occupation [To be specified – important for repetitive strain injuries]

Source Patient (self)

Reliability Reliable, alert, and able to provide clear history

Allergies No Known Drug Allergies (NKDA) – confirm

Chief Complaint: "My arm feels weak" or "I can't lift my arm
like I used to"
Encounter Type: Outpatient clinic visit
Week 3 Focus: Neurological and Musculoskeletal Assessment

PART 2: PAST MEDICAL HISTORY (PMH)
Condition Details Relevance

Hypertension [Duration, control] Stroke risk factor

, Condition Details Relevance

Stroke risk factor,
Diabetes Mellitus [Type, duration, control]
neuropathy

Hyperlipidemia [Duration, treatment] Stroke risk factor

Can cause weakness,
Thyroid disease [Hypo/hyper, treatment]
neuropathy

Autoimmune Lupus, rheumatoid arthritis, Can cause neurologic
disorders multiple sclerosis symptoms

Previous
Any history? Critical risk factor
stroke/TIA

May have aura with
Migraine headaches History?
weakness

Cervical spine
Prior diagnosis? Radiculopathy
issues

Arthritis Osteoarthritis, rheumatoid Joint involvement

Key Questions:
 Any prior episodes of weakness or numbness?
 Any history of stroke, transient ischemic attack (TIA), or
mini-strokes?
 Any history of multiple sclerosis or other neurological
conditions?
 Any history of neck or back problems?
 Any history of autoimmune diseases?