Feb 23, 2024 NURS 6512 Case Study Assignment 1 Week 9 Assessing Neurological Symptoms
NURS 6512 Case Study Assignment: Assessing Neurological Symptoms
NURS 6512 Case Study Assignment Assessing Neurological Symptoms
Patient Information:
A.Y, 20 year-old African American male
S.
CC “I have been experiencing intermittent headaches that diffuse all over the head with greatest intensity and pressure above the eyes.”
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HPI: The patient came with complaints of intermittent headaches for the last one week. The headaches diffuse all over the head with greatest intensity and pressure above the eyes and spreads through the nose, cheekbones, and jaw. The client reports that analgesics such as acetaminophen provide him with relieve that is not long lasting. The associated symptoms include nausea and photophobia. The severity of pain as reported by the patient was 8/10.
Current Medications: The patient has been using acetaminophen 1 gm TDS for the last four days.
Allergies: The client denied any food, drug, or environmental allergy.
PMHx: The client’s immunization history is up to date. Soc Hx: The client is a college student undertaking a degree in information technology. He does not smoke or take alcohol. He engages in active physical activity, as he is a member of the university basketball team. His social support comprises of his family members and friends.
Fam Hx: The client denied any chronic illnesses in the family.
ROS:
GENERAL: The patient appeared well-groomed for the occasion without any signs of malaise or weight loss. He denied fever and chills.
HEENT: Eyes: The client denied visual loss, blurred vision, double vision or yellow sclerae. He reported photophobia during the episodes of intermittent headaches.
Ears, Nose, Throat: He denied hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: He denied rash, scars, or itching.
CARDIOVASCULAR: He denied chest pain, chest pressure, chest discomfort, palpitations or edema.
RESPIRATORY: He denied shortness of breath, difficulty in breathing, cough or sputum.
GASTROINTESTINAL: Denies anorexia, vomiting or diarrhea. He also denied abdominal pain or blood. He reported nausea during episodes of intermittent headaches.
GENITOURINARY: He denied burning on urination, increased urinary frequency, or changes in smell and color of urine.
NEUROLOGICAL: The patient reports intermittent headaches, denies syncope, dizziness, paralysis, numbness, and tingling of the extremities. He also denied changes in bladder and bwel control.
MUSCULOSKELETAL: The patient denied muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: He denied anemia, bleeding or bruising.
LYMPHATICS: He denied enlarged nodes with absence of a history of splenectomy.
PSYCHIATRIC: He denied history of depression or anxiety.
ENDOCRINOLOGIC: He denied history of sweating, cold or heat intolerance. He also denied polyuria or polydipsia.
ALLERGIES: He denied history of asthma, hives, eczema or rhinitis.
O.
Physical exam:
General: The patient appears well groomed, with lack of evidence of weight loss and fatigue
Vitals: Temp 36.7, BP 122/76 P-80, RR 20, SPO2 96,
Head: normocephalic, with no lesions, evidence of trauma, with symmetric facial features. The maxillary and frontal sinuses are tender on palpation.
Ears: The ears are symmetric with absence of ear drainage, loss of balance, and grey tympanic membranes
Eyes: the eyes are symmetric, without jaundice and bleeding. Normal visual acuity
Nose: Absence of nasal flaring, discharge, and septum deviation
Throat: Absence of tonsillitis
Neck: symmetric trachea noted with absence of neck rigidity, swelling, and gross abnormalities of the thyroid
Cardiovascular: presence of S1 and S2, with absence of peripheral edema and advantageous sounds
Gastrointestinal: Absence of abdominal swelling, scars, with normal bowel movements.
Respiratory: Lung sounds clear with absence of advantageous sounds
Neurological: Client is oriented to self, place, time, and events. Pupil reactive to light and equal in size with equal grip in both hands and symmetrical facial features. The self-reported headache is rated at 8/10. There is the presence of intermittent headache, photophobia, and nausea.
Diagnostic results: One of the recommended diagnostic investigations that should be performed for the client is nasal scrapping. Nasal scraping should be performed to obtain a sample for test for esinophils. Radiological investigations are also recommended in case of severe symptoms. The investigations include a head CT scan to detect any abnormalities such as tissue involvement, inflammation of the meninges, and tumors. A MRI may also be done to determine the presence of any abnormality in the brain tissue and soft tissue pathology. Bacterial sinusitis may also be diagnosed by performing sinus aspiration (Iskandar & Triayudi, 2020).
A.
Differential Diagnoses
Sinusitis: The first differential diagnosis for the client in this case study is sinusitis. Sinusitis is a condition characterized by the inflammation of the nasal cavities. The symptoms often last for a period of less than a month. Patients with sinusitis experience symptoms that include frontal headaches with feelings of fullness. Patients also experience other accompanying symptoms that include nausea, vomiting, photophobia, and nasal drainage. The physical assessment findings may reveal tenderness of the sinuses (Iskandar & Triayudi, 2020). The patient in the case study has symptoms that align with this diagnosis, hence, it being the primary diagnosis.
Migraine headache: migraine headache is the secondary diagnosis for the patient in this case study. Patients with migraine headache experience severe, throbbing headache. The accompanying symptoms include photophobia, phonophobia, nausea, and vomiting (Ha & Gonzalez, 2019). This is however a least diagnosis because of the patient experiencing feelings of fullness and involvement of the sinuses.
Allergic rhinitis: The other possible diagnosis for the client is allergic rhinitis. Patients with allergic rhinitis experience symptoms that include headaches, nasal drainage, coughing, sneezing, and pressure on the cheeks and nose (Scadding et al., 2017). Allergic rhinitis is however the least likely diagnosis due to the absence of a history of allergic reaction by the client.
Facial pain syndrome: Facial pain syndrome is the other potential diagnosis for the client in the case study. Facial pain syndrome is attributed to pain affecting the trigeminal nerve. The symptoms associated with it include pain on touching the face, speaking, chewing or brushing teeth (Benoliel & Gaul, 2017). Facial pain syndrome is however the least likely diagnosis due to the absence of pain upon stimulation of the facial muscles.
Acute bacterial pharyngitis: Acute bacterial pharyngitis is the last potential diagnosis for the client. Acute bacterial pharyngitis is attributed to step bacterial infection. Patients experience symptoms that include difficulty in swallowing, headache, chills, and malaise. The patient however does not experience difficulty in swallowing, fever, and chills, hence, acute bacterial pharyngitis not being the primary differential (Harberger & Graber, 2021).
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Benoliel, R., & Gaul, C. (2017). Persistent idiopathic facial pain. Cephalalgia, 37(7), 680–691. https://doi.org/10.1177/0333102417706349
Ha, H., & Gonzalez, A. (2019). Migraine Headache Prophylaxis. American Family Physician, 99(1), 17–24.
Harberger, S., & Graber, M. (2021). Bacterial Pharyngitis. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK559007/
Iskandar, A., & Triayudi, A. (2020). Early Diagnosis of Sinusitis Using Expert System Methods: Early Diagnosis of Sinusitis Using Expert System Methods. Jurnal Mantik, 4(2), 1231–1236. https://doi.org/10.35335/mantik.Vol4.2020.927.pp1231-1236
Scadding, G. K., Kariyawasam, H. H., Scadding, G., Mirakian, R., Buckley, R. J., Dixon, T., Durham, S. R., Farooque, S., Jones, N., Leech, S., Nasser, S. M., Powell, R., Roberts, G., Rotiroti, G., Simpson, A., Smith, H., & Clark, A. T. (2017). BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007). Clinical & Experimental Allergy, 47(7), 856–889. https://doi.org/10.1111/cea.12953
Differential Diagnosis:
1) Diabetic neuropathies- given that the patient has a history of diabetes and that the condition is caused by the metabolic disorder hyperglycemia, which results in impaired insulin secretion, this diagnosis seems conceivable. This syndrome gives rise to the clinical signs that the patient presents with, including tingling and numbness (McCance & Huether, 2019).
2) Hypothyroidism- considering that the patient’s tingling sensation and weight gain were clinical signs of low levels of thyroid hormone, likely resulting from a thyroid gland abnormality (Agency for healthcare research and quality, 2016).
3) Alcohol associated neuropathy- given that the patient recalls using alcohol and that numbness is one of the condition’s clinical symptoms, it is possible that this is the cause of the loss of feeling in part of the nerves (McCance & Huether, 2019).
4) Guillain-Barre syndrome-is a disorder where the body’s immune system targets the nerves. The patient reported feeling tingling in their hands and possibly elevated blood pressure, therefore this is a reasonable diagnosis (McCance & Huether, 2019).
5) Vitamin B-12 deficiency- this illness is caused by the body having less vitamin B-12 than usual, which may result in clinical symptoms like the numbness the patient has reported (Agency for healthcare research and quality, 2016).
Primary Diagnosis: Diabetic neuropathies
References
McCance, K. L., Huether, S. E., BRASHERS, V. L., & ROTE, N. S. (2019). Pathophysiology: The biologic basic for diseases in adults and children (No. ed. 8). Elsevier
Petropoulos, I. N., Ponirakis, G., Khan, A., Almuhannadi, H., Gad, H., & Malik, R. A. (2018). Diagnosing diabetic neuropathy: something old, something new. Diabetes & metabolism journal, 42(4), 255.
YEAR, F. (2016). Agency for healthcare research and quality.
Episodic/Focused SOAP Note Template
Patient Information:
The client is a 20-year-old male who his ethnicity has not been stated.
S.
CC (chief complaint)
The client is a 20-year-old male client who came to the hospital with complains of experiencing intermittent headaches. The headaches diffuse all over the head but greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.
HPI: The history of headache is not given. However, the client reports that the headaches diffuse all over the head with greatest intensity and pressure occurring above the eyes and spreading through the nose, cheekbones and jaw:
Location: headache all over the head with worsening intensity and pressure occurring above the eyes and spreading through the nose, jaw and cheekbones
Onset: intermittent in nature and occurring frequently
Character: Diffusive headache with greater intensity and pressure above the eyes and spreads through the nose, cheekbones and jaw
Associated signs and symptoms: photophobia and nausea
Timing: Timing varies making it intermittent in nature. It however occurs frequently
Exacerbating/ relieving factors: taking pain relieving medications such as acetaminophen
Severity: 9/10
Current Medications: the patient does not currently takes any medications.
Allergies: the client is allergic to pollen.
PMHx: The client does not have any significant medical or surgical history. The immunization history of the patient is up-to-date.Soc Hx: information on social history not provided.
Fam Hx: There is no significant family history of chronic or mental illnesses.
ROS:
GENERAL: The patient appears alert, with no evidence of weight loss, fever, chills or fatigue
HEENT: The patient complains of experiencing intermittent headaches. The headaches diffuse all over the head but greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw The patient denies any complains of hearing loss, ear ache or drainage from the ears. The patient denies tinnitus, loss of body balance, blurred vision, eyes drainage, sore throat, difficulty in swallowing and swollen lymph nodes. The patient also denies sneezing or difficulty in breathing. The patient reports photophobia associated with high intensity headache.
SKIN: The patient denies rash or itching or changes in skin color.
CARDIOVASCULAR: The patient denies chest pain, chest tightness, chest discomfort, palpitations or edema.
RESPIRATORY: The patient denies any history of difficulty in breathing, shortness of breath, or coughing.
GASTROINTESTINAL: The patient reports anorexia, nausea and vomiting associated with intermittent headaches.
GENITOURINARY: The patient denies dysuria, burning sensation on urination, or changes in the color and smell of urine.
NEUROLOGICAL: The experiences intermittent headaches. The headaches diffuse all over the head but greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw patient denies headache. The patient denies any history of dizziness, loss of sensations, numbness, tingling of the extremities, or paralysis.
MUSCULOSKELETAL: The patient denies any history muscle weakness and pain, joint pain, and difficulties in walking.
HEMATOLOGIC: The patient denies any history of bleeding.
LYMPHATICS: The patient denies any history of lymphadenopathy
PSYCHIATRIC: The patient denies any history of psychiatric illness in the family
ENDOCRINOLOGIC: The patient denies sweating, cold or heat intolerance.
ALLERGIES: The patient denies any history of asthma, hives, eczema or rhinitis.
O.
Physical exam: HEENT: The patient complains of experiencing intermittent headaches. The headaches diffuse all over the head but greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw. On examination, the head is symmetric and does not have any visible scars or evidence of trauma. The neck moves in full range of motion without any rigidity. Facial features are symmetrical without any tremors, tics or drooping.
The sinuses are tender on palpation. The ears are symmetrical with absence of drainage, and erythema of the tympanic membrane. On the assessment of the eyes, there is no drainage; sclera is clear, pupil equal and responsive to light. On assessment of the nose, there is no septum deviation, bleeding or nasal flaring. On the assessment of the throat, the tonsils are pink with no swelling or erythema.
Diagnostic results: One of the diagnostic investigations that are recommended for the client is nasal scrap. A nasal scrap should be performed to obtain a sample for analysis for the presence of cells such as esinophils, which would indicate the presence of allergic reaction (Cingi & Muluk, 2019). A CT scan of the head may be indicated in case of severe symptoms. Head CT scan would reveal the extent of the disease and involvement of the brain structures. It will also aid in the determination of whether the intermittent headaches are due to malignant tumors of the brain or not (Leone & May, 2019).
Magnetic resonance imaging (MRI) may also be performed if CT scan does not reveal conclusive findings. MRI will reveal the involvement of soft tissues of the brain and any abnormality that may be contributing to the health problem affecting the patient (Suen & Petersen, 2018). The MRI will also guide in diagnosing the client with conditions such as metabolic disorders, nerve palsies, and pathology of the internal auditory canal.
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses).
The top three differential diagnoses include the following:
Migraine headache
Allergic rhinitis
Acute sinusitis
One of the differential diagnoses for the client is migraine headache. Patients experiencing migraine headache often experience symptoms such as unilateral throbbing headache, photophobia, vomiting, and nausea (Durand & Deschler, 2018). The client might be suffering from a migraine headache that does not have aura. According to evidence, migraine headache without aura contributes to about 80% of the cases of migraine headaches that are diagnosed in healthcare settings.
Factors such as stress, exposure to strong stimuli and hormonal changes contribute to the development of migraine headaches (Chinthapalli et al., 2018). The patient in the case study reported symptoms that align with those of migraine headache, making it one of the differential diagnoses. The second differential diagnosis for the client is allergic rhinitis. Allergic rhinitis refers to a condition that comprises of symptoms affecting the nasal cavity. The symptoms develop due to the exposure of the clients to substances that they have developed sensitivity towards them. Often, clients experience frontal, pressure headache that is similar to that experienced by the patient in the case study (Cingi et al., 2017).
As a result, allergic rhinitis may be considered as the potential cause of the health problem affecting the client. The last differential diagnosis for the client is acute sinusitis. Acute sinusitis refers to the inflammation of the nasal membranes and sinuses. The disease is largely attributed to infections such as those caused by bacteria and viruses. Individuals with weakened immunity, smoke tobacco, and have history of intranasal allergies have an increased risk of developing acute sinusitis. Patients with acute sinusitis experience symptoms such as nasal congestion, mucous discharge from the nose, headache, pain, tenderness or pressure behind the nose, eyes, or cheeks, and fatigue (David & Benoit, 2017). The patient in the case study is experiencing some of the above symptoms, hence, making acute sinusitis a primary diagnosis.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Chinthapalli, K., Logan, A.-M., Raj, R., & Nirmalananthan, N. (2018). Assessment of acute headache in adults – what the general physician needs to know. Clinical Medicine, 18(5), 422–427. https://doi.org/10.7861/clinmedicine.18-5-422
Cingi, C., Gevaert, P., Mösges, R., Rondon, C., Hox, V., Rudenko, M., Muluk, N. B., Scadding, G., Manole, F., Hupin, C., Fokkens, W. J., Akdis, C., Bachert, C., Demoly, P., Mullol, J., Muraro, A., Papadopoulos, N., Pawankar, R., Rombaux, P., … Bousquet, J. (2017). Multi-morbidities of allergic rhinitis in adults: European Academy of Allergy and Clinical Immunology Task Force Report. Clinical and Translational Allergy, 7(1), 17. https://doi.org/10.1186/s13601-017-0153-z
Cingi, C., & Muluk, N. B. (2019). All Around the Nose: Basic Science, Diseases and Surgical Cingi, Cemal, & Bayar Muluk, N. (2020). All around the nose: Basic science, diseases and surgical management. https://doi.org/10.1007/978-3-030-21217-9
David, M., & Benoit, J.-L. (2017). The Infectious Disease Diagnosis: A Case Approach. Springer.
Durand, M. L., & Deschler, D. G. (2018). Infections of the Ears, Nose, Throat, and Sinuses. Springer International Publishing.
Leone, M., & May, A. (2019). Cluster Headache and other Trigeminal Autonomic Cephalgias. Springer.
Suen, J. Y., & Petersen, E. (2018). Diagnosis and Management of Head and Face Pain: A Practical Approach. Springer.
Imagine not being able to form new memories. This is the reality patients with anterograde amnesia face. Although this form of amnesia is rare, it can result from severe brain trauma. Anterograde amnesia demonstrates just how impactful brain disorders can be to a patient’s quality of living. Accurately assessing neurological symptoms is a complex process that involves the analysis of many factors.
In this Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
To Prepare
By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
With regard to the case study you were assigned:
Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study you were assigned.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
The Case Study Assignment
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Week 8: Assessment of the Musculoskeletal System
Case Study 2
Patient name: Angel Rodriguez Age: 46 Gender: Female Ethnicity: Hispanic
Angel Rodriguez is a 46-year-old Hispanic female with complaints of pain in both of her ankles, but more pain and concern about the right ankle. She heard a “pop” when she was playing soccer this past weekend. She has the ability to bear weight, but expresses some discomfort.
SUBJECTIVE DATA:
Chief Complaint (CC): “I have pain in both my ankles, but more in the right.”
History of Present Illness (HPI): AR is a 46 years-old-female who presents to the clinic for bilateral ankle pain for 3 days. The pain started after she was playing soccer over the weekend and noticed a “pop” sound while playing. She reports the pain as “throbbing, sore, and sharp.” She can bear weight on both ankles but the pain is worse on the right. Her pain is a 6/10 on the severity scale. The pain increases to a 9/10 on the right ankle when ambulating or standing for an extended amount of time. AR has been elevating her ankles on pillows and applied heat and ice packs with no relief. She reports her right ankle is swollen and tender to touch. Currently her pain is 3/10 on the left ankle and 8/10 on the right ankle.
Current Medications
Multivitamin PO daily- name unknown
Ibuprofen 800 mg Q6 PRN for pain
Tylenol 650 mg Q6 PRN for pain
Allergies:
No drug, food, seasonal, or animal allergies.
Past Medical History (PMH): No recent hospitalizations were reported. Broke left wrist in May 2015. Osteoporosis at age 45.
Past Surgical History (PSH): No surgery history.
Sexual/Reproductive History: Last menstrual cycle was 3 weeks ago. Engaged to fiance for 8 months. Fiance is AR’s only sexual partner.
Personal/Social History: AR’s occupation is a Recreational Therapist at University of Chapel Hill (UNC)- Nash for 5 years. Her fiance and her own their home for the past year. They only share their home with 2 dogs. Rodriguez enjoys playing soccer, reading, shopping, and volunteering at her neighborhood garden. She drinks 2-3 glasses of wine every weekend. She denies smoking tobacco/vapes and illicit street drugs.
Immunization History:
Influenza: 09/13/2022. 46 years old.
Hep B: 3 dose series completed at 6 months old.
Hep A: 2 dose series completed at 15 months old.
Pneumococcal: 4 dose series completed at 15 months old.
DTaP: 5 dose series completed at 6 months old.
MMR: 2 dose series completed at 6 months old.
Varicella: 2 dose series completed at 6 months old.
Polio: 4 dose series completed at 7 months old.
Significant Family History:
Mother- age 76, DM2, HTN, HLD,
Father- age 74- tobacco smoker, HTN, COPD
Maternal Grand-mother- deceased- age 88- CVA
Maternal Grand-father- deceased- age 86- MI, tobacco smoker, COPD, HTN
Paternal Grand-mother- age 87- HTN
Paternal Grandfather- deceased- age 85- CVA
ROS:
General: Reports feeling fatigued and “extra tired” from ambulating/bearing weight on her ankles. Reports lack of sleep due to pain.
HEENT:
Head: No headaches reported. Denies dizziness.
Eyes: Denies problems with eyes. Denies eye itching, redness, watery or pain. Does wear reading eyeglasses.
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