Feb 23, 2024 NUR5 6512 Assignment 1 Case Study Assignment Assessing Neurological Symptoms
NUR5 6512 Assignment 1 Case Study Assignment Assessing Neurological Symptoms
NUR5 6512 Assignment 1 Case Study Assignment Assessing Neurological Symptoms
Patient Information:
Initials: J.K.L
Age: 40 years
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Sex: Female
Race: African American
Source: Patient
S.
CC: “I have a headache around my forehead.”
HPI: J.K.L is a 40-year-old African American female who presents with a complaint of a headache across her forehead for a week. The headache is squeezing and feels like pressure behind the eyes. It is non-radiating. The headache is constant and varies in severity ranging from 2/10 at its best to 8/10 at its worst. It is usually worse in the morning and while bending. Acetaminophen reduces the severity of the headache to 4/10 and occasionally 2/10. It is associated with fever, postnasal drip, nasal congestion, sneezing, and occasional non-productive cough. She takes Sudafed HCL 120 mg every 12 hours to obtain some relief. The symptoms have significantly impaired her concentration at work and made her feel very tired. Finally, she reports a head cold three weeks ago.
Current Medications: Pseudoephedrine 120 mg BID for nasal congestion and acetaminophen for headaches.
Allergies: She has no known food and drug allergies.
Past Medical History: During her last visit to the primary care physician 2 months ago, she was noted to be prehypertensive and was advised on lifestyle modifications. No prior hospitalization. No previous surgeries or blood transfusions.
Social History: She is married with two children both alive and well. She works as a secretary Her husband is a college teacher. She neither drinks alcohol nor smokes tobacco. She does not use marijuana or other illicit drugs. She strictly adheres to dietary advice from her nutritionist and she exercises regularly. Denies caffeine intake.
Family History: Father alive aged 60 years and with hypertension while her mother is 58 years old alive and well. Her brother and sister are 35 and 20 years old respectively, alive and well. Her paternal grandfather died at the age of 80 years due to a heart attack while her paternal grandmother is 78 years and is hypertensive. Her maternal grandfather is 77 years with a history of type 2 diabetes and high cholesterol while her maternal grandmother died at the age of 70 years due to a stroke. No family history of malignancies, mental illness, asthma, sickle cell, or diabetes.
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ROS:
GENERAL: Reports fatigue and occasional fever. Denies weight loss, night sweats, and chills.
HEENT: Reports headaches, nasal congestion, post nasal drip, and sneezing. No blurring of vision, visual loss, hearing loss, tinnitus, nose bleeds, ear pain, mouth sores, or sore throat.
SKIN: no skin lesion or rashes. No abnormal pigmentation.
CARDIOVASCULAR: Negative for palpitations, chest pain, paroxysmal nocturnal dyspnea, and peripheral limb edema.
RESPIRATORY: Occasional non-productive cough. No difficulty in breathing, dyspnea, or orthopnea.
GASTROINTESTINAL: Reports loss of appetite and occasional nausea and vomiting. Denies change in bowel habits, abdominal pain, or distention.
GENITOURINARY: No frequency, dysuria, nocturia, and polyuria. No vaginal itchiness or abnormal vaginal discharge.
NEUROLOGICAL: Reports headache. Denies dizziness, lightheadedness, numbness, tingling, loss of sensation, syncope, and convulsion.
MUSCULOSKELETAL: No muscle pain, joint pains, muscle weakness, or muscle swelling.
HEMATOLOGIC: No anemia, easy bruising, or bleeding.
LYMPHATICS: Normal lymph nodes
PSYCHIATRIC: Denies anxiety, depression, suicidal ideations, or hallucinations.
ENDOCRINOLOGIC: Denies heat or cold intolerance, polyphagia, and polydipsia.
ALLERGIES: Reports no allergies.
O.
Physical exam:
VITAL SIGNS: BP 125/78 mmHg, HR 88 b/min, Temp 99. 8 F, RR 20 b/min, saturation 95% on room air, Height 168 cm, weight 76 Kg. Pain level 5/10
GENERAL: A middle-aged African-American female, well kempt, not in any form of respiratory distress but slight discomfort. Maintains eye contact, coherent speech, and a stable mood. Well-hydrated and nourished. No palmar or conjunctival pallor, jaundice, central or peripheral cyanosis, cervical or inguinal lymphadenopathy, and peripheral limb edema.
HEENT: Normocephalic and atraumatic head. Non-tender scalp. Bilateral eyes with pink conjunctiva and white sclera. Pupils equally and bilaterally reacting to light, no ptosis or lid edema. Normal extraocular movements. Bilateral ears present, no impaction or skin lesions, tympanic membrane pearly grey bilaterally, and positive white reflex. Both nares are present and are discharging mucus, midline nasal septum, and pink and soft nasal mucosa. Tender maxillary and frontal sinus. Moist and pink oral mucosa, no oral lesions or ulceration. Normal dentition and teeth alignment.
NECK: Soft neck. The trachea is central. Full range of motion, non-tender, no cervical lymphadenopathy, and no thyroid enlargement.
CARDIOVASCULAR: Regular heart rate. Normoactive precordium. Point of maximal impulse in the 5th intercostal space in the midclavicular line. S1 and S2 head, no murmurs, thrills, gallops, rubs, or heaves.
RESPIRATORY: Symmetrical chest that moves with respiration. No scars or skin lesions. Equal chest expansion and equal tactile fremitus bilaterally. Equal air entry, vesicular breath sounds, no wheezes, and crackles, and equal vocal fremitus in all lung zones.
NEUROLOGICAL: GCS 15/15, oriented to time, place, and person, intact short-term and long-term memory, good concentration, and a clear coherent speech. Cranial nerves 1 to 12 intact. Normotonic across all joints, normal bulk, and power 5/5 across all muscle groups in upper and lower extremities, deep tendon reflexes 2+ and equal bilaterally in upper and lower limbs. Intact monofilament sensation across all dermatomes, good bowel, and bladder function. No spinal tenderness, normal gait, coordination, graphesthesia, and stereognosis. Normal finger nose, heel to the shin, and rapid alternating movements tests.
Diagnostic results:
J.K.L appears to have an inflammatory/infectious condition. Consequently, complete blood count and inflammatory markers particularly CRP and ESR are paramount. Similarly, bacterial or fungal cultures obtained endoscopically or by direct sinus aspiration are required to identify the possible pathogen. Additionally, a skin prick test is essential to exclude allergic rhinitis. Imaging modalities principally Sinus CT and MRI are recommended to evaluate for rhinosinusitis and intraorbital or intracranial involvement.
A.
Differential Diagnoses
Acute Sinusitis- refers to the inflammation of sinuses lasting less than 4 weeks (DeBoer & Kwon, 2022). The condition is more common in females and particularly during early fall to early spring (DeBoer & Kwon, 2022). It is most commonly caused by viral infection following a common cold although bacteria and fungi are not uncommon etiologies. J.K.L presents with clinical features that are typical of acute sinusitis including fatigue, fever, headache, facial pain, and pressure worse on bending (DeBoer & Kwon, 2022). Maxillary sinuses and frontal sinuses appear to be the affected sinuses in her as evidenced by pain around the forehead and tenderness of the maxillary and frontal sinuses (DeBoer & Kwon, 2022).
Rhinitis- Refers to the inflammation of the nasal mucosa. J.K.L presents with clinical manifestations suggestive of rhinitis including sneezing, nasal congestion, postnasal drip, and rhinorrhea (Liva et al., 2021). Similarly, she reports a “head cold” three weeks ago. Rhinitis is mostly caused by an upper respiratory infection or type 1 hypersensitivity reaction (Liva et al., 2021). However, an upper respiratory tract infection is likely the cause in her case.
Cluster headache- Cluster headache is a type of primary headache that is usually unilateral retro-orbital and characterized by sharp and stabbing pain (Goadsby et al., 2018). Cluster headache may present with symptoms of lacrimation, nasal congestion, rhinorrhea, ptosis, or miosis (Goadsby et al., 2018). However, it is unlikely the diagnosis in her as cluster headache usually lasts for a brief period. Similarly, cluster headaches mostly awake the patient at night.
Migraine headache- Migraine headache is another type of primary headache that may be preceded with or without aura. It is usually pulsating and moderate to severe (Pescador Ruschel & O, 2022). It is common in young women. However, it is unlikely the diagnosis as migraines last 4 to 72 hours if untreated and are typically associated with nausea, vomiting, photophobia, and phonophobia (Pescador Ruschel & O, 2022).
Rebound headache– Commonly referred to as medication overuse headache. Rebound headache predominantly occurs in individuals with primary headaches who overuse analgesia (Micieli & Robblee, 2018). Rebound headaches are more common in females and individuals less than 50 years. Drugs precipitating this headache include barbiturates, acetaminophen, opioids, ergotamine, and triptans (Micieli & Robblee, 2018). However, this is an unlikely diagnosis in J.K.L as a diagnosis of primary headache hasn’t been established.
References
DeBoer, D. L., & Kwon, E. (2022). Acute Sinusitis. https://pubmed.ncbi.nlm.nih.gov/31613481/
Goadsby, P., Wei, D.-T., & Yuan Ong, J. (2018). Cluster headache: Epidemiology, pathophysiology, clinical features, and diagnosis. Annals of Indian Academy of Neurology, 21(5), 3. https://doi.org/10.4103/aian.aian_349_17
Liva, G. A., Karatzanis, A. D., & Prokopakis, E. P. (2021). Review of rhinitis: Classification, types, pathophysiology. Journal of Clinical Medicine, 10(14), 3183. https://doi.org/10.3390/jcm10143183
Micieli, A., & Robblee, J. (2018). Medication-overuse headache. Journal de l’Association Medicale Canadienne [Canadian Medical Association Journal], 190(10), E296–E296. https://doi.org/10.1503/cmaj.171101
Pescador Ruschel, M., & O, D. J. (2022). Migraine Headache. https://pubmed.ncbi.nlm.nih.gov/32809622/
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes neededSoc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
Patient Information:
Initials: JH Age: 33 years old Sex: Female Race: Hispanic
S.
CC: “The right side of my face has been dropping since morning.”
HPI: JH is a 33-year-old Hispanic female who came to the hospital complaining of her right face ‘drooping.’ She claims that the feeling started in the morning on the same day that she came to the hospital. She also complains of excessive tearing and drooling on the whole of her right side. She is however in no pain.
Location: right side of the face
Onset: in the morning
Character: drooping face
Associated signs and symptoms: excessive tearing and drooling on her right side
Timing: In the morning
Exacerbating/ relieving factors: none has been mentioned
Severity: not specified
Current Medications: None
Allergies: No known allergies to drugs, food or any environmental factor.
PMHx: No history given. No surgical history.Soc Hx: Occupational and major hobbies in addition to family status has not been provided.
Fam Hx: Family history has not been provided.
ROS:
GENERAL: Denies weight loss, chills, fever, fatigue or general weakness.
HEENT: Eyes: Confirms excessive tearing. Denies visual loss, double vision, blurred vision, or yellow sclerae. Ears, Nose, Throat: Denies, hearing loss, congestion, sneezing, sore throat or runny nose.
SKIN: Denies itching or skin rash
CARDIOVASCULAR: Denies chest pain, chest discomfort or chest pressure. No edema or palpitations.
RESPIRATORY: Denies breathing problems, shortness of breath, sputum or cough. No shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies nausea or vomiting, diarrhea or anorexia. Denies abdominal pain or bleeding.
GENITOURINARY: Denies burning on urination, painful urination or excessive urine frequency.
NEUROLOGICAL: Confirms drooping of the right side of the face. Confirms drooling on her right side. Denies headache, syncope, dizziness, ataxia, paralysis. Denies any change in bladder or bowel control.
MUSCULOSKELETAL: Denies muscle or joint pain or stiffness.
HEMATOLOGIC: Denies bleeding, bruises or history of anemia.
LYMPHATICS: Denies enlarged lymph nodes or any history of organomegaly.
PSYCHIATRIC: Denies any history of anxiety, depression or mania.
ENDOCRINOLOGIC: Denies excessive sweating, excessive cold or heat intolerance. Denies polydipsia or polyuria.
ALLERGIES: Denies any history of asthma attacks, eczema, hives, rhinitis or any allergic reactions.
O.
Physical exam:
GENERAL: The patient is fatigued with general body weakness. Fever & chills are also present. No weight gain or weight loss.
HEAD: Her head is normocephalic and atraumatic with no injury
EENT: Eyes: white sclera, pinkish conjunctiva, no jaundice or pallor. Presence of excessive tearing in the right eye, no movement on the eyebrows, eyelid opening is normal; lower lid is sagging. Ears, Nose, Throat: No hearing problems, sneezing, running nose, sore throat or congestion. The nasolabial fold is absent on the right side. Presence of drooling on her right side, no movement of lips and mouth slightly open on the left side.
SKIN: Normal warm skin with no lesions, itching or dryness.
CARDIOVASCULAR: No murmurs. Heart rhythm and heart rate is normal, with good S1 &S2 sound and no S3 & S4. No signs of peripheral edema.
RESPIRATORY: No breathing problems, respiration is even and unlabored. No cough, sputum or shortness of breath.
GASTROINTESTINAL: soft abdomen with no tenderness on palpation. Presence of bowel sounds in all of the four quadrants.
NEUROLOGICAL: Paralysis of the right facial nerve.
MUSCULOSKELETAL: ROM, no joint pain, back pain or stiffness.
LYMPHATICS: No signs of enlarged lymph nodes.
Diagnostic results: unilateral, single episodes that involve all the nerve branches is an indication of Bell’s palsy. Consequently, studies show that unequal distribution of weakness on different zones of the face on physical examination suggests Bell’s palsy (Eviston et al., 2015). This condition occurs at any age above two years, but most commonly experienced by individuals between the age of 15 to 45 years. It is also important to check for the presence or absence of other associated symptoms such as dry eyes, synkinesis, and pain to be able to rule out other differential diagnoses. From the physical examination, the patient is suspected of having an acute unilateral facial palsy which is a significant indication of Bell’s palsy. Other imaging tests such as needle electromyography (EMG), CT scan, and MRI are necessary for ruling out other conditions with the same symptoms (Wiggins, & Ashok, 2015). Serological test for Borrelia Burgdorferi should also be requested, such that a negative result will indicate bell’s palsy as a possible diagnosis.
A.
Differential Diagnoses:
Bell’s Palsy: Bell’s palsy is a neurological condition characterized by an acute unilateral palsy of the peripheral facial nerve. The diagnosis of this condition is normally confirmed in patients of whom medical history and physical examination are unremarkable, including deficits that affect all the zones of the face equally, and fully resolve within three days. Bell’s palsy leads to a sudden weakness of the facial muscles temporarily, which makes one side of the face to droop (Eviston et al., 2015). The patient in the assigned case scenario is positive for most of the indicating signs and symptoms of Bell’s palsy making this condition the most appropriate diagnosis.
Lyme disease: This is a bacterial infection that is transmitted by a vector, infected black-legged tick which is commonly referred to as the deer tick. Prolonged infection causes injury to the neurological system that may present as paralysis on one side of the face, weakness in both limbs, numbness, and impaired movement of muscles (Wormser et al., 2015).
Facial nerve schwannoma: This is a type of a primary benign intracranial tumor of the vestibular nerve of the myelin-forming calls. The main sign and symptoms of this condition is the slow progression of facial nerve paralysis which causes drooping of the face, which the patient in this case study is positive for (Slattery, 2014). Additional symptoms include hearing loss, vestibular symptoms, pain, and tinnitus.
Idiopathic orofacial granulomatosis (Melkersson-Rosenthal syndrome): This condition is characterized by insidious and slowly progressive paralysis of the facial nerve. The parotid mass is usually palpable upon physical examination (Miest et al., 2017).
Cerebrovascular accident (CVA): This condition is commonly known as stroke, and it is caused by blockage or rupture of blood vessels supplying blood to the brain. It is characterized by numbness and paralysis in the face which the patients positive for, among other symptoms (Karliński, Gluszkiewicz, & Członkowska, 2015). These symptoms include difficulty in walking, loss of balance and coordination, dizziness, blurred or darkened vision, a sudden headache that is accompanied by nausea and vomiting and difficulty in speaking.
P.
N/A
References
Eviston, T. J., Krishnan, A. V., Croxson, G. R., Kennedy, P. G. E., & Hadlock, T. (December 01, 2015). Bell’s palsy: Aetiology, clinical features, and multidisciplinary care. Journal of Neurology, Neurosurgery, and Psychiatry, 86(12), 1356-1361.
In Slattery, W. H. (2014). The facial nerve. New York, NY: Thieme.
In Wiggins, R. H., & In Ashok, S. (2015). Head and neck imaging. Philadelphia, PA: Elsevier.
Karliński, M., Gluszkiewicz, M., & Członkowska, A. (January 01, 2015). The accuracy of prehospital diagnosis of acute cerebrovascular accidents: an observational study. Archives of Medical Science, 11(3), 530-535.
Miest, R. Y., Bruce, A. J., Comfere, N. I., Hadjicharalambous, E., Endly, D., Lohse, C. M., & Rogers, R. S. (January 01, 2017). A Diagnostic Approach to Recurrent Orofacial Swelling: A Retrospective Study of 104 Patients. Mayo Clinic Proceedings, 92(7), 1053-1060.
Wormser, G. P., Weitzner, E., McKenna, D., Nadelman, R. B., Scavarda, C., & Nowakowski, J. (January 01, 2015). Long-term assessment of fatigue in patients with culture-confirmed Lyme disease. The American Journal of Medicine, 128(2), 181-4.
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