Case Study Assignment: Assessing Neurological Symptoms Essay.
Case Overview: Case Study #3: 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.Case Study Assignment: Assessing Neurological Symptoms Essay.
Patient Initials: Mrs. R. S.
Chief Complaint (CC): Right-sided facial droop
History of Present Illness (HPI): the patient is a 33-year-old who presented at the ED unit complaining of right-sided facial droop that was associated a two-day history of diminished taste, an ipsilateral facial numbness, and a moderate frontal-occipital pulsating headache. She reported having similar headaches four weeks before the presentation. She had additional symptoms of dull and severe chest pains.Case Study Assignment: Assessing Neurological Symptoms Essay.
Past Medical History (PMH): up to date with all immunizations, she has a history of insomnia. She denied any history of a chronic underlying medical history such as diabetes mellitus, hypertension, cancer, stroke, allergies, seizure disorders, or MI.Case Study Assignment: Assessing Neurological Symptoms Essay.
Past Surgical History (PSH): no history of major or minor surgical history
OB/GYN History: LMP 01/24/2021
Cervical and Vaginal Cytology:
Personal/Social History: currently enrolled in a Master’s Program for Business Administration. The patient is employed full-time as a manager in a private organization for the last 8 years. She has been married for 10years in a monogamous marriage. She lives in Minneapolis with her husband and two children. She is a Baptist and regularly attends church. She heads the women’s fellowship and volunteers in the children’s ministry twice a month at a local food bank program. She holds social gatherings monthly and weekly date nights. She denied tobacco smoking, she is a social drinker and takes 4-5 units of alcohol monthly especially during social gatherings. She denies recreational and illicit drug use
Family History: She has two siblings; a younger sister who is asthmatic and an elder brother who is alive and healthy. Both parents are also alive and healthy with no history of a chronic underlying familial illness.Case Study Assignment: Assessing Neurological Symptoms Essay.
Review of Systems (ROS)
Constitutional: the patient appears independently in the office, she denies unintentional weight loss or gain, denies fevers, chills, sore throat, night sweats.
HEENT: patient admits to feeling dizzy, associated with a pulsating intermittent frontal-occipital headache, and loss of taste. She however denied having changes in vision, loss of vision, blurred vision, trauma to the head, she does not use corrective lenses. She denies pain, or ringing in the ears, and hearing loss, and denied abnormal ear discharge. Denied sores and ulcerations in the gums, tongue, and cheeks, denied difficulty swallowing, closing, or opening jaws, denied hoarseness. She also denied swelling or lumps in the neck, and pain with movement.Case Study Assignment: Assessing Neurological Symptoms Essay.
Cardiovascular: has moderate dull chest pains, denied palpitations, denied swelling of the upper and lower extremities and facial swelling, and denied inability to take part in sports/physical activity, and history of murmurs.
Respiratory: the patient denied shortness of breath, and difficulty breathing without or with activity. Denied coughing and wheezing. She denied exposure to influenza A and TB, Her last annual flu immunization was on 10/2020. She denied a history of current or chronic respiratory disease or exposure to second-hand smoke at work or home.Case Study Assignment: Assessing Neurological Symptoms Essay.
Gastrointestinal: she denied vomiting, nausea, diarrhea, constipation, abdominal pain apart from menstrual cramping, she described her stool as light-brown-brown and soft, she denied black or tarry stools, and blood in stool.
Genitourinary: the patient denied pain or burning on urination, frequency, and urgency. She also denied lower back pain or flank pain. Her urine is yellow, no blood-stains, or foul odor. No vaginal sores. Her last LMP was on 01/24/2021.Case Study Assignment: Assessing Neurological Symptoms Essay.
Psychiatric: the patient admitted to new-onset emotional disturbances after the onset of symptoms of a right-sided facial droop, denied feeling blue or sad, increased tiredness, auditory and visual hallucinations, and thoughts of self-harm and suicidal ideations
Gynecological: patient denies vaginal sores, her last LMP was on 01/24/2021, normal, 30-day30-day cycle, she denied intermenstrual bleeding, admits to abdominal cramping during menses, denies having excess vaginal discharge, green-colored or yellow-colored vaginal discharge, denied a foul-smelling vaginal discharge, vaginal itching, STI exposure. She is married in a monogamous relationship and does not engage in high-risk sexual behavior.Case Study Assignment: Assessing Neurological Symptoms Essay.
Endocrine: she denied excess thirst, micturition, cracked skin, denied changes in weight, excess growth, or loss of hair.
Neurologic: the patient reports a moderate headache (pulsatile) frontal-occipital, she also reports dizziness, but denies memory loss, seizures, tingling
Hematologic/lymphatic: the patient denied both familial and self-anemia, denied spontaneous bleeding or bruising, prolonged healing from bruising or cuts.Case Study Assignment: Assessing Neurological Symptoms Essay.
Allergic/immunologic: denied medical, environmental, and food allergies.
General: a middle-aged Caucasian female well-groomed, somnolent, and AOX4 spheres.
Vital Signs-Temp 97.1, RR-18, BP-162/93, Weight-147 pounds, Height-5’7, PR-
HEET: Head: normocephalic with no bruising, lesions, and masses. Clean hair with no scalp scaling, non-tender on palpation and percussion of the maxillary and frontal sinuses. Eyes: PERRLA, no exudates, eyelid lesions, or crusting. No enophthalmos, exophthalmos, or periorbital edema. Her vision- is 20/20 RE, 20/20 LE. Her retina is intact bilaterally, with no evidence for bilateral intraocular bleeding or cataracts. Ears: intact hearing is intact, no ear discharge, swelling, or redness on the inner and outer structures of the ear.Case Study Assignment: Assessing Neurological Symptoms Essay. The bilateral assessment of the tympanic membrane revealed that the tympanic membrane was shiny, gray, and intact. Nose/Mouth/Throat: intact, pink, and moist mucus membranes, no evidence of bruising, bleeding, and swelling of the turbinates. The nares have fine hairs with no deviation from the sputum. No sores, wounds, or exudates on the tongue, cheeks, and tongue. The membranes of the oral mucosa are moist, pink, and intact. She has no halitosis or dental caries. She has natural teeth, no pain with chewing, and no pain on the jawline with palpation and percussion. Neck/Lymph: supple, no lymphadenopathy, edema, or tenderness on palpation of both axillae. There is no pain with hyperflexion, hyperextension, or rotation from left to right. There is no jugular distension or carotid bruit.Case Study Assignment: Assessing Neurological Symptoms Essay.
Cardiovascular/Peripheral Vascular: the patient has normal heart sounds, S1 and S2 heard, no gallops, murmurs, or rubs. Heart rate is 75BPM regular, +2 brachial, radial, pedal, and femoral pulses, normal HR elevation with activity, and baseline return with rest, normal color for ethnicity, no upper or lower limb and facial edema.
Respiratory/Chest/Breast: symmetrical chest wall, left and right breast has the same size, her nipples protrude outwards, has a dark areola with intact skin, no palpable masses or lumps, no discharge from the nipples, or tenderness with rotation. The lungs are bilaterally clear, the breathing is normal and rhythmic with no accessory muscles use. On auscultation, there are no abnormal breath sounds (crackles, wheezing, rhonchi, or rales). No clubbing.Case Study Assignment: Assessing Neurological Symptoms Essay.
Neurologic: the patient is A0X4, follows commands, recalls past three days events, her speech and coordination were slow. She had a right facial droop. Had an intact depth of perception, deep tendon reflexes were intact.
Musculoskeletal: no edema, can distinguish touch, had a normal color for her ethnicity and her lower and upper muscle extremities had developed symmetrically. She had a full range of motion (FROM) on all joints. Her left strength was 5/5, right-3/5 RUE, and 4/5 RLE with slow coordination.
Head CT Scan: this radiologic test is important to help in excluding a likely intracerebral hemorrhage, an epidural and subdural hematoma.
MRI Scan: to detect possible hemorrhages and infarctions in the brain
Random/Rapid Blood glucose (RBG): an RBG is essential to help in ruling out hyper or hypoglycemia that can subsequently result in stroke symptoms.Case Study Assignment: Assessing Neurological Symptoms Essay.
CBC (Complete Blood Count): a CBC is important in identifying and detecting blood disorders such as anemias, clotting problems, bleeding disorders, and cancers.
Lipid panel: a lipid panel can demonstrate the patient’s risk of thrombosis or coronary heart disease.
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.Case Study Assignment: Assessing Neurological Symptoms Essay.
In this Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
With regard to the case study you were assigned:
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. Case Study Assignment: Assessing Neurological Symptoms Essay.
Case Study #3-
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.
See below comments from the instructor on previous work which can help in this assignment
When writing your initial post, be sure to follow the SOAP template format. Insert or discuss the information that you would want to have to arrive at your list of differentials. Be specific…ie: when discussing ROM. You need to indicate….FROM of left shoulder, etc… be specific in how you document.Case Study Assignment: Assessing Neurological Symptoms Essay.
Your differentials are all looking good. Be sure to list in reverse chronological order…..most suspected to least suspected. I have been challenging you to also think out of the box with those differentials. Just because we are working on a musculoskeletal unit…..doesn’t mean it is necessarily a musculoskeletal issue. It could me other medical issues, such as in this past week….back pain could be contributed to an abdominal aneurysm or even a kidney infection. The answer may not always be as black and white as you thing. Think outside the box
Case Study Assignment: Assessing Neurological Symptoms Essay.