Assessment For Patients With Neurological Essay

Assessment For Patients With Neurological Essay

Assessment For Patients With Neurological Disorders

Focused SOAP Assessment

Patient’s particulars

Chief complaint

Drooping, excessive tearing, and drooling on her right side of the face that began this morning

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. Assessment For Patients With Neurological Essay

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.

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

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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.

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,

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).

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.

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The post to write a response to is as follows: The patient is a 46-year old obese woman with hypertension and a family history of breast cancer. She complains of hot flushes, genitourinary symptoms, and night sweats. Close to 95% of women enter menopause at around 45 -55 years (Rosenthal & Burchum, 2021). Our patient is in menopause, and due to low estrogen levels, she has vasomotor symptoms. The health needs of this patient are relief of vasomotor symptoms, genitourinary symptoms, improving the quality of life, and minimizing risks of breast cancer and venous thromboembolism. Genitourinary syndrome of menopause does not subside unless managed and can negatively affect the patient’s quality of life (Roberts & Hickey, 2016). The standard for the management of vasomotor symptoms in menopause is hormonal therapy. This therapy, however, has an associated risk of breast cancer, cardiovascular disease, and endometrial cancer (Stubbs et al., 2017). The treatment plan for this patient will include. To treat genitourinary symptoms, I will initiate the patient on non-hormonal therapy such as lubricants, dilation therapy, and moisturizers since the patient is at a high risk of developing breast cancer (Kagan et al., 2019). If she does not respond to the non-hormonal treatment, she will be given low-dose hormonal therapies such as vaginal tablets and creams. The education strategy for this patient would be to establish a good rapport. I would then explain to her about menopause and emphasize that it is a normal physiological process associated with the symptoms that she is experiencing (Rosenthal & Burchum, 2021). Throughout the decision-making process, I will also involve her in explaining the risk and benefits of available therapy options, which will help her make an informed decision.

References

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.

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.

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