CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS NURS 6512

CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS NURS 6512

CASE STUDY ASSIGNMENT ASSESSING NEUROLOGICAL SYMPTOMS NURS 6512

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:

A 20-year-old male

S.

CC ‘I am experiencing intermittent headaches diffusing all over the head.’

HPI: The client is a 20-year-old African American male that came to the unit with complaints of

intermittent headaches. The duration of the headache is not given. The character of the headaches is that it diffuses all over the head with greatest intensity and pressure above the eyes. The headache also spreads through the jaw, nose, and cheekbones. The associated symptoms include nausea and photophobia. The relieving factors for the headache include taking analgesics such as Tylenol. The self-reported pain by the client on pain rating scale is 8/10.

Current Medications: The current denies current use of any medications.

Allergies: The client reports that he does not have any history of drug allergy. He is however allergic to cats and pollen. He reports that he develops rhinorrhea, swollen eyes, and symptoms of asthma when exposed to the allergens.

PMHx: The immunization history of the client is up-to-date. He reports that he was admitted to the hospital at the age of 15 years due to pneumonia. He is asthmatic. He manages it using corticosteroid inhaler. He does not have history of blood transfusion or surgeries.

Soc Hx: The client is a university student. He lives with his family. He has two brothers. He does not smoke or take alcohol. He does not have a current or previous history of substance abuse. He wears seatbelt whenever driving. He considers his family to be the source of his social support. He engages in active physical activities, as he is part of the soccer team in the university.

Fam Hx: There is no significant family history of mental illness or chronic diseases.

ROS:

GENERAL:  The patient is dressed appropriately, alert, oriented with no evidence of weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  The patient reports intermittent headaches. The headaches diffuse all over the head with greatest intensity and pressure occurring above the eyes and spreading through the jaw, nose, and cheekbone. He reports photophobia when the intensity of headache is high.  The patient denies visual loss, blurred vision, double vision or yellow sclerae. He also denies hearing loss, sneezing, congestion, runny nose or sore throat. He also denies difficulty in swallowing, lymphadenopathy, and difficulty in breathing.

SKIN:  The patient denies the presence of rash or itching.

CARDIOVASCULAR:  The patient denies chest pain, chest pressure or chest discomfort. He also denies palpitations or edema.

RESPIRATORY:  He denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  He denies anorexia, nausea, vomiting or diarrhea. He also denies abdominal pain or blood.

GENITOURINARY:  He denies burning on urination, increased urinary frequency and urgency or changes in the color and smell of urine.

NEUROLOGICAL:  The patient reports intermittent headaches. The headaches diffuse all over the head with greatest intensity and pressure occurring above the eyes and spreads through the nose, jaw, and cheekbones. He denies any history of dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. He also denies changes in bowel or bladder control.

MUSCULOSKELETAL:  He denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  He denies anemia, bleeding or bruising.

LYMPHATICS:  He denies enlarged nodes. No history of splenectomy

PSYCHIATRIC:  He denies any history of depression or anxiety.

ENDOCRINOLOGIC:  He denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia

ALLERGIES:  No history of drug allergy but presence of allergic reaction to pollen and cats

O.

Physical exam:

Vital signs: Temp 36.6 C, RR 18, HR 80, BP 129/67, SPO2 96 at room air

HEENT: The head appears normocephalic with no evidence of trauma. The neck moves in a full range of motion without any rigidity, swelling, or lymphadenopathy. The facial features are symmetrical with absence of drooping or signs of paralysis. The sinuses are tender on palpation. The eyes are symmetrical with the patient hearing whispering bilaterally. There are no signs of ear infection such as drainage or erythema of the tympanic membranes. The eyes have no drainage with pink conjunctiva and whit sclera. There is normal reaction of pupils to light. There is no septum deviation, rhinorrhea, or nasal flaring. There is no difficulty in swallowing, halitosis, or swelling of the peritonsilar area.

Diagnostic results: One of the recommended diagnostics for the client is nasal scrap. A nasal swab should be taken for laboratory investigation of any white blood cells such as leucocytes, which would indicate upper respiratory tract infection such as sinusitis. The other recommended investigation is complete blood count. A complete blood count will provide insights into any abnormal biomarkers such as lymphocytes and leucocytes that would indicate an underlying infection.

Radiological investigations such as CT scan and MRI should be undertaken to determine the actual cause of the intermittent headaches. The radiological investigations will guide in ruling out causes such as tumors and changes in the myelin sheath due to conditions such as meningitis (Frost et al., 2019). Sinus aspiration may also be done to rule out bacterial sinusitis.

A.

Sinusitis: The primary differential that should be considered for the patient in the case study is sinusitis. Sinusitis is an infection of the sinuses that cause inflammation of the nasal cavities. Patients experience symptoms such as headache, feelings of fullness, nasal drainage, photophobia, vomiting and nausea. The sinuses also feel tenderness on palpation. The symptoms of the patient in the case study align with those of sinusitis. For example, the patient has intermittent headaches radiating to the cheekbone, jaw and nose, tender sinuses on palpation, and photophobia (Frost et al., 2019). Therefore, he is likely to be suffering from sinusitis.

Migraine headache: The secondary diagnosis for the client is migraine headache. Migraine headache is a disorder that is mainly characterized by symptoms such as vomiting, throbbing headache, nausea, and photophobia. Migraine headache without aura is the commonest in populations. Patients are predisposed to migraine headache due to factors such as hormonal changes and persistent exposure to stress.

The patient has positive symptoms for migraine headache such as intermittent headache and photophobia (Ha & Gonzalez, 2019). However, the presence of symptoms such as sinus tenderness rules out the possibility of the patient suffering from migraine headache.

Allergic rhinitis: Allergic rhinitis is the third differential that may be considered for the client. The need for the consideration is the client’s history of allergic reaction to cats and pollen. Patients develop allergic rhinitis when they are exposed to allergens. They develop symptoms such as running nose, coughing, sneezing, headache, and feelings of pressure on the nose and cheekbone. The client has positive symptoms of allergic rhinitis such as headache. He however experiences negative symptoms such as sinus tenderness and absence of nasal drainage or sneezing and coughing (Hoyte & Nelson, 2018). Therefore, allergic rhinitis is the least likely diagnosis.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Frost, H. M., Gerber, J. S., & Hersh, A. L. (2019). Antibiotic Recommendations for Acute Otitis Media and Acute Bacterial Sinusitis. The Pediatric Infectious Disease Journal, 38(2), 217. https://doi.org/10.1097/INF.0000000000002085

Ha, H., & Gonzalez, A. (2019). Migraine Headache Prophylaxis. American Family Physician, 99(1), 17–24.

Hoyte, F. C. L., & Nelson, H. S. (2018). Recent advances in allergic rhinitis. F1000Research, 7, F1000 Faculty Rev-1333. https://doi.org/10.12688/f1000research.15367.1

Case Study Assignment

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:

Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS NURS 6512

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:

1. Migraine headache
2. Allergic rhinitis
3. 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.

Patient Information:  T.J., 15 years old,  African American Male

S.

CC  “Both Knees hurt, especially when I walk upstairs. Sometimes I hear clicking sound along with this strange catching sensation under my knee”

HPI:

TJ is 15 -year-old African American male with bilateral patellar pain, dull in nature and  localized  around anterior knee area. The pain started 3 days ago and was associated with walking up and downstairs, running, and squatting. The knee pain frequently  comes with a “clicking” noise and catching sensation under patella. Severity described as 7/10 .

Reports that Aleve makes it tolerable,  but not completely better. Takes 1 caplet 220 mg q 8-12 hours. Exacerbating factors reported by the client are walking, jumping, and squatting.

Current Medications: Aleve 220 mg every 8-12 as needed for pain . No RX medications, no other over the counter medications.

Allergies:

No known allergies. Denies food , environmental and latex allergies.

PMHx:

Up to date on all his immunizations, last COVID booster in April 2022, last flu vaccine December 2021.

Fractured right tibia three years ago while playing football, Denies history of arthritis, rheumatic fever, or Lyme disease. Denies any prior surgeries and /or hospitalizations.

SocHx: TJ identifies himself as “heterosexual”, but he is not sexually active. He lives with his parents. Denies any tobacco , alcohol, or illicit drug use. TJ is a high school student at Thomas Jefferson High school. He enjoys playing sports , football is his favorite sport. He is a wide receiver on the school football team. TJ runs in the morning and goes to the gym during the afternoons.  TJ wears his seatbelt whenever riding in a motor vehicle , reports getting 8-10 hours of sleep a night. He likes spending time with his friends and going movies.

Fam Hx: T.J parents are both still living. Dad 49 years old has history of HTN, Peptic ulcers, and gout . Mom 51-year-old has CHF and HTN. His younger brother does not have any significant health history.

ROS:

GENERAL:  TJ does not have weight loss, denies fever, chills, weakness or fatigue.

HEENT:  Eyes:  Denies blurred or loss vision. Denies double vision. No  yellowsclerae noted.

 Ears, Nose, Throat:  Reports no hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. Denies  palpitations or edema.

RESPIRATORY:  Denies  shortness of breath, cough or sputum production.

GASTROINTESTINAL: Denies intestinal discomfort, nausea, vomiting or diarrhea. Reports no abdominal pain or blood.

GENITOURINARY:  Reports No Burning on urination.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. Reports no change in bowel or bladder control.

MUSCULOSKELETAL: positive for bilateral patellar pain , tenderness, and slight edema around Right and left knee.

HEMATOLOGIC: reports no anemia, bleeding or bruising.

LYMPHATICS: denies enlarged nodes and  history of splenectomy.

PSYCHIATRIC: reports no depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema, or rhinitis.

O.

Physical exam:

Temp 98.6 F, Pulse 60, respirations 20and non labored. SPO2 100% on room air, BP 125/78mmhg. Weight 136 lbs, H5’8’’

Diagnostic tests:

CT scan, MRI, and Xray.

Blood Tests:

CBC (inflammation and infection screening), Erythrocyte Sedimentation Rate(Inflammation screening) , Uric Acid (rule out gout), Rheumatoid Factor (rheumatoid factor)  

Differential Diagnoses

1. Patellofemoral Pain Syndrome .The  main cardinal feature of pain around anterior knee that worsens with descending stairs , squatting , and bending knee during weight bearing activities(Gaitonde, 2019).
2. Patellar dislocation or Fracture . The main feature of this diagnosis is that occurs mostly in adults younger than 20 years old and accounts for more than 93% of the cases. It is usually the result of trauma or twisting tibia during physical activities(Ball, 2019), (Thijie,2019).
3. Bursitis .It is an inflammation of the bursa that results in tenderness of the knee and knee pain. (Daines et al., 2019).
4.  Chondromalacia Patella(Runner’s knee) is a disease of the hyaline cartilage coating of the articular surfaces of the bone (Habusta et aal, 2019).
5. Osgood-Schlatter Disease (OSD) – A condition in which the patellar ligament insertion on the tibial tuberosity ends up inflamed (Vaishya et al., 2018).

References

Gaitonde, D. Y., Ericksen, A., & Robbins, R. C. (2019). Patellofemoral Pain Syndrome. American family

                    physician, 99(2), 88–94.

https://pubmed.ncbi.nlm.nih.gov/