Assessing Neurological Symptoms Essay Paper
Assessing Neurological Symptoms Essay Paper
Subjective Data
Chief complaint: “I am having a cold headache for three weeks now”
History of presenting complaint: O.O is a 40years old female who presented at the ER presenting with a headache in the frontal region. It is of acute onset, moderate to severe, does not radiate, and increases in intensity on bending. Acetaminophen relieves the headache to 4/10 and occasionally mild to 2/10. The headache is associated with fever, mild coughing, sneezing, pressure behind the eyes, inability to breathe out of the nose, and mucus running down the throat. Assessing Neurological Symptoms Essay Paper
Past medical history: the patient denies hospitalization, history of chronic illness, blood transfusion, and surgical procedure. Her immunization schedule is up to date.
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Allergies: the patient denies food and drug allergy.
Social history: the patient is married and lives with her husband and her two children. She has studied up to college and has a diploma in accounting. She works as an assistant accountant in a micro-finance firm.
Family history: the patient is the last born in a family of three. Her 60years old mother has asthma and hypertension. Her 66years old father has diabetes mellitus and sinusitis. Her elder sister has hypertension and migraine headaches. Her brother is obese and asthmatic. She denies a family history of cancer.
Review of system
General: the patient has a mild intermittent fever. However, she denies fatigue, night sweats, and weight loss.
HEENT: the patient has a headache, running nose, and fullness of the face. She denies blurring of vision, hearing loss, throat pain, and ear pain.
Respiratory system: the patient has a mild cough, sneezing, difficulties breathing through the nose, and running nose. She denies chest pain, wheezing, fast breathing, and respiratory distress.
Cardiovascular system: the patient denies awareness of heartbeat, syncope, orthopnea, paroxysmal nocturnal dyspnea, and lower limb edema.
Gastrointestinal system: the patient has reduced appetite. She denies abdominal pain, vomiting, nausea, heartburn, reflux, and constipation.
Genitourinary system: the patient denies dysuria, hematuria, flank pain, vaginal discharge, and urine incontinence. Assessing Neurological Symptoms Essay Paper
Objective Data
General examination: the patient is calm and oriented. She has no pallor, jaundice, cyanosis, lymphadenopathy, and finger clubbing.
Vitals: blood pressure is at 134/68mmHg, pulse rate at 88beats per minute, height 151cm, weight 60kgs, and respiratory rate 14beats per minute.
HEENT: the head is a traumatic round with no scar and mass. The eyes are congested and reddish. There is nasal mucosal erythema and edema. There are purulent secretions within the middle meatus. She has facial tenderness
Chest examination: the chest wall has a symmetrical expansion upon inspiration and expiration. There is no scar, mass, or bruising at the chest wall. The heart is normal-active at 5th ICS MCL. There is a resonant percussion note over the lung fields. However, there are no parasternal heaves, thrills, and rubs. The clung fields are clear with no crackles, stridor, and rhonchi. The heart sounds S1 S2 is present. There are no murmurs and bruits.
Abdominal examination: the abdomen is round and has a normal contour. There is no scar and flank fullness. The bowel sounds are present and regular in the four quadrants. There is a tympanic percussion note. There is no shifting dullness and fluid thrill. There is no organ enlargement.
Diagnostic Tests
- Plain radiographic examination
- Multiplanar sinus CT helps in evaluating sinusitis
- Maxilla-mandibular MRI helps rule out nerve injury
Assessment
The patient presents with headache, fever, mild coughing, sneezing, pressure behind the eyes, inability to breathe out of the nose, and an allergic mucus running down the throat. Upon examination, she has red eyes, postnasal drip, erythematous nasal mucosa, and facial tenderness. Therefore, my differential diagnoses are chronic sinusitis, allergic rhinitis, cluster headaches, tension headache, and nasal polyp.
Chronic sinusitis is the inflammation of the paranasal sinuses accompanying rhino-sinusitis. Chronic sinusitis can be infectious or non-infectious. Non-infectious sinusitis is associated with allergies, exposure to environmental pollutants, GERD, and cystic fibrosis. The presenting symptoms are nasal blockage, congestion, and stuffiness. The patient may present with post-nasal drip, sneezing, facial pain, fullness, headache, throat pain, unproductive cough, and unexplained fever (Kwon, E., & O’Rourke, M. C. 2020). This is the actual patient diagnosis because she presents with both major and minor factors. The major factors are nasal blockage, facial pain, fever, nasal discharge, and anosmia. The minor factors are cough, headache, fatigue, and dental pain. Assessing Neurological Symptoms Essay Paper
Cluster headache is also known as neurovascular headache disorder. it presents with an acute severe headache that is usually unilateral. The headache is intermittent and lasts days to weeks. It is associated with conjunctival injection, lacrimation, nasal congestion, rhinorrhea, ptosis, and eyelid edema. The headache is worse during sleep hours and morning hours with a corresponding onset of rapid eye movement (Wei, D. Y., & Goadsby, P. J. 2021). Neuroimaging and intracranial and cervical vasculature and the sellar of the paranasal region would be of help in making the appropriate diagnosis. The patient has similar symptoms like headache, mild coughing, nasal congestion, and rhinorrhea. However, this is not the patient’s actual diagnosis because she presents with a frontal headache that is worse at night worse on bending and is associated with fever. Assessing Neurological Symptoms Essay Paper
Allergic rhinitis is the inflammation of the nasal membranes characterized by sneezing, nasal congestion, itchiness, rhinorrhea, postnasal drip, anosmia, headache, tearing, fatigue, drooling, and eye swelling (Hoyte, F. C., & Nelson, H. S. 2018). Often, it causes apnea, otitis media, and sinusitis. Allergic rhinitis is a result of environmental triggers like cold, fur, and dust. This is not the actual diagnosis because the patient does not have any environmental trigger at the onset of the symptoms. Additionally, she has a fever and facial fullness, which are classical signs of chronic sinusitis.
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Nasal polyps are abnormal lesions originating from the nasal mucosa of the paranasal sinuses. They are common in patients with recurrent fungal sinusitis, bronchial asthma, allergic rhinitis, and chronic sinusitis (Bachert, et al, 2020). The presenting signs and symptoms are nasal obstruction, postnasal drainage, dull headaches, rhinorrhea, anosmia, and epistaxis. The patient presents with similar symptoms. She has a positive history of sinusitis. An otologic speculum and rhinoscope are appropriate in confirming the diagnosis. Assessing Neurological Symptoms Essay Paper
Tension headache is an acute onset headache that is pressing or tight at the frontal occipital region. it is bilateral and of moderate to severe intensity. It is not aggravated by physical activities. The pain lasts for 30minutes for 7days a week. The pain is associated with nausea, vomiting, photophobia, insomnia, muscle tightness, and difficulties in concentrating (Cheraghi, et al, 2018). The patient presents with a headache in the frontal region that persists for three weeks. However, this is not the actual diagnosis because the patient’s headache is associated with fever, mild coughing, sneezing, pressure behind the eyes, inability to breathe out of the nose, and mucus running down the throat. Assessing Neurological Symptoms Essay Paper
