Assessment For Patients With Neurological essay paper

Assessment For Patients With Neurological essay paper

Assessment For Patients With Neurological essay paper

Assessment For Patients With Neurological Disorders

Drooping, excessive tearing, and drooling on her right side of the face that began this morning Assessment For Patients With Neurological essay paper

History of the presenting complaint

R.R is a 33 years old female who presents with facial drooping, excessive tearing, and drooling on the right side of the face since morning. It was of acute onset, associated with poor eyelid closure on the right side, tingling or numbness of the right cheek, blurring of vision on the right eye, and taste disturbances. The patient cannot describe the aggravating and relieving factors.

PMH

The patient is known to have the retroviral disease and has been on HAART for 15 years. She is also known to have hypertension and she is on follow-up. She was previously admitted to the hospital for one month due to hypertension emergency associated with left-sided weakness. She states that her previous viral load was undetectable. Assessment For Patients With Neurological essay paper

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Current medication: She is on HAART first-line therapy, losartan 50mg once daily, and hydrochlorothiazide 50mg once a day.

Allergies: The patient is allergic to penicillin (hives)

Personal social-economic history: The patient is single and lives with her four children who are of three different fathers. She works as a primary school teacher. She smokes tobacco and drinks gin every weekend. She relates well with her family and friends.

Family history: She is the firstborn in a family of five. Her siblings are alive and healthy. Her parents are suffering from hypertension and are on follow-up.

Surgical history; she has undergone three caesarian sections in her last three deliveries.

Reproductive history: she is para4+0 with four living children. Her first delivery was spontaneous vertex term delivery whose outcome was a live male child 2300g. her second delivery was through a caesarian section at term due to breech presentation whose outcome was a live male infant at 2600g. The third delivery was through a cesarian section at term due to one previous scare and the fourth delivery was through a cesarian section at preterm at 35 weeks due to premature labor with two previous scars.

Review Of Systems

General: she denies a history of fever, weight loss, and persistent fatigue. Assessment For Patients With Neurological essay paper

HEENT:

Eyes: she has blurred vision on the right eye and excessive tearing.

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

Skin: no rash or itching.

Cardiovascular: denies chest pain, chest pressure or chest discomfort, or edema.

Respiratory: She denies cough or sputum, chest pain.

Gastrointestinal: denies having diarrhea and constipation, abdominal discomfort and cramping, incomplete emptying of the bowel, and unexplained weight loss.

Genitourinary: denies burning on urination, age of menopause 49years

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

Musculoskeletal: she experiences facial muscle weakness, no muscle pain, back pain, joint pain, or stiffness.

Hematologic: no anemia, bleeding, or bruising.

Lymphatics: has enlarged nodes, no history of splenectomy.

Endocrinology: no reports of sweating, cold, or heat intolerance. No Polyuria or Polydipsia.

Reproductive: she denies reports of vaginal discharge, she is sexually active, Assessment For Patients With Neurological essay paper

Allergies: has a history of hives when he takes penicillin’s

Objective Data

Physical examination

The patient is clinically afebrile with poor eyelid closure, upper eyelid retraction, ectropion of the lower lid, flattening of the forehead, and nasolabial fold on the right side of the face. The vitals are blood pressure 189/94mmHg, pulse 78beats per minute, and temperature 36.4.

Neurological examination

There is a facial nerve injury due to drooling and drooping. The facial nerve excitability test is positive for bell palsy due to facial twitching. The muscle bulk of the upper and lower limbs is normal. The power is at 5 out of 5, the tone is normal, and the reflexes are intact. The patient is oriented to time, place, and person.

Diagnostic investigations

Blood glucose, thyroid function test, erythrocytic sedimentation rate, head computed tomography and magnetic resonance imaging, CSF analysis, and complete blood count.

Assessment

Differential diagnoses for this patient are bell palsy, right-sided stroke, basilar meningitis, Guillain barre syndrome, and base of skull fracture. Bell palsy is idiopathic facial paralysis as a result of a neurologic disorder of the cranial nerve. Bell palsy presents with upper and lower facial paralysis, facial drooping, drooling, and tearing of the affected side. Patients with Bell palsy experience facial numbness or tingling sensation, blurring of vision, and reduced eyelid closure (Yoo, et al, 2020). Stroke is defined as reduced or interrupted blood supply to the part of the brain due to trauma or elevated blood pressure. Stroke presents with paralysis, weakness or numbness of the face or arms, blurring of vision (Katan, & Luft, 2018, April).  Assessment For Patients With Neurological essay paper

Basilar Meningitis is a meningococcal brain infection that is characterized by fever, facial paralysis, severe headache, generalized body fatigue, and hemiparesis (Onda, et al, 2018). Guillain barre syndrome is a collection of clinical syndromes that manifest as an acute inflammatory with resultant weakness and diminished reflexes. It presents with facial drooping, dysphagia, ophthalmoplegia, facial flushing, orthostatic hypotension, and slurring of speech (Shahrizaila, et al, 2021). According to (Solai, et al, 2018), basilar skull fracture is the fracture of the longitudinal temporal bone that may present with loss of consciousness, facial palsy, facial numbness, nystagmus, and ataxia. Assessment For Patients With Neurological essay paper

Katan, & Luft, (2018, April). Global burden of stroke. In Seminars in neurology (Vol. 38, No. 2, pp. 208-211). Georg Thieme Verlag.

Onda, A., Miyagawa, S., Gomi, T., Horino, T., Kamei, K., & Yaguchi, H. (2018). A case of histoplasmosis with chronic basilar meningitis was diagnosed relatively early. Rinsho shinkeigaku= Clinical neurology, 58(4), 241-244.

Physical Examination—Objective Data

 VS

TPR, BP, Ht, Wt

General Appearance

Age, race, gender, posture and gait

Mental Status

Consciousness, cognitive ability, memory, emotional stability, thought content, speech quality

Head

Scalp, temporal arteries, deformities

Eyes

Pupils (PERRLA), EOMs (CN III, IV, VI), light reflex, visual fields, funduscopy (CN II), acuity (CN II), nystagmus

Ears

Hearing (Rinne, Weber, CN VIII)

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Mouth and Throat

Lips/teeth/gums, tongue (CN XII), mucosa, palates, tonsils, exudate, uvula, gag reflex (CN IX, X)

Chest/Lungs

Shape, movement, respirations (rate, rhythm), expansion, accessory muscles, tactile fremitus, crepitus, percussion tone, excursion, auscultation (clear, wheeze, crackles, rhonchi, rubs)

Heart

PMI, lifts, thrills, rate, rhythm, S1, S2, splitting, gallops, rubs, murmurs, snaps

Musculoskeletal

Posture, alignment, symmetry, joint heat/swelling/color, muscle tone, ROM, strength

Neurologic

CN II-XII, rapid alternating movements, finger-to-nose, sensation, vibration, stereognosis, motor system, gait, Romberg, deep tendon reflexes (DTRs), superficial reflexes Assessment For Patients With Neurological essay paper

Cranial Nerves

I: Smell

II: Visual acuity, visual fields, funduscopy

III, IV, VI: Eyelid opening EOMs: IV up and out, VI lateral, III all others

V: Corneal reflex, facial sensation (3 areas), jaw opening, bite strength

VII: Eyebrow raise, eyelid close, smile, taste

VIII: Rinne, Weber

IX, X: Gag reflex, palate elevation, phonation

XI: Lateral head rotation, neck flexion, shoulder shrug

XII: Tongue protrusion, lateral deviation strength

References

Shahrizaila, N., Lehmann, H. C., & Kuwabara, S. (2021). Guillain-Barré syndrome. The Lancet.

Solai, C. A., de Alencar Domingues, C., de Souza Nogueira, L., & de Sousa, R. M. C. (2018). Clinical signs of basilar skull fracture and their predictive value in the diagnosis of this injury. Journal of Trauma Nursing| JTN, 25(5), 301-306. Assessment For Patients With Neurological essay paper

Yoo, M. C., Soh, Y., Chon, J., Lee, J. H., Jung, J., Kim, S. S., … & Yeo, S. G. (2020). Evaluation of factors associated with favorable outcomes in adults with Bell palsy. JAMA Otolaryngology–Head & Neck Surgery, 146(3), 256-263. Assessment For Patients With Neurological essay paper

For this assignment you will create a focused/episodic note on your assigned case study. Then provide at least 5 differential diagnoses with rationales for each diagnosis.
CASE STUDY 1: Drooping of Face
A 33-year-old female comes to your clinic alarmed about sudden “drooping” on the right side of the face that began this morning. She complains of excessive tearing and drooling on her right side as well.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 23, “Neurologic System”
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis. Assessment For Patients With Neurological essay paper
Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”)
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.
Rubric
Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned.
Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.
Excellent 45 (45%) – 50 (50%)
The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
Good 39 (39%) – 44 (44%)
The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
Fair 33 (33%) – 38 (38%)
The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected.
Poor 0 (0%) – 32 (32%)
The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. Assessment For Patients With Neurological essay paper
Excellent 30 (30%) – 35 (35%)
The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study and provides a thorough, accurate, and detailed justification for each of the five conditions selected.
Good 24 (24%) – 29 (29%)
The response lists four to five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected.
Fair 18 (18%) – 23 (23%)
The response lists three to four possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or some inaccuracy in the conditions and/or justification for each.
Poor 0 (0%) – 17 (17%)
The response lists three or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected. Assessment For Patients With Neurological essay paper