NURS 6512 Case Study Assignment 1 Week 9 Assessing Neurological Symptoms

A Sample Answer For the Assignment: NURS 6512 Case Study Assignment 1 Week 9 Assessing Neurological Symptoms

Title: NURS 6512 Case Study Assignment 1 Week 9 Assessing Neurological Symptoms

NURS 6512 Case Study Assignment: Assessing Neurological Symptoms

NURS 6512 Case Study Assignment Assessing Neurological Symptoms

Patient Information:

A.Y, 20 year-old African American male

S.

CC “I have been experiencing intermittent headaches that diffuse all over the head with greatest intensity and pressure above the eyes.”

HPI: The patient came with complaints of intermittent headaches for the last one week. The headaches diffuse all over the head with greatest intensity and pressure above the eyes and spreads through the nose, cheekbones, and jaw. The client reports that analgesics such as acetaminophen provide him with relieve that is not long lasting. The associated symptoms include nausea and photophobia. The severity of pain as reported by the patient was 8/10.

Current Medications: The patient has been using acetaminophen 1 gm TDS for the last four days.

Allergies: The client denied any food, drug, or environmental allergy.

PMHx: The client’s immunization history is up to date.

Soc Hx: The client is a college student undertaking a degree in information technology. He does not smoke or take alcohol. He engages in active physical activity, as he is a member of the university basketball team. His social support comprises of his family members and friends.

Fam Hx: The client denied any chronic illnesses in the family.

ROS:

GENERAL:  The patient appeared well-groomed for the occasion without any signs of malaise or weight loss. He denied fever and chills.

HEENT:  Eyes: The client denied visual loss, blurred vision, double vision or yellow sclerae. He reported photophobia during the episodes of intermittent headaches.

Ears, Nose, Throat:  He denied hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  He denied rash, scars, or itching.

CARDIOVASCULAR:  He denied chest pain, chest pressure, chest discomfort, palpitations or edema.

RESPIRATORY:  He denied shortness of breath, difficulty in breathing, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, vomiting or diarrhea. He also denied abdominal pain or blood. He reported nausea during episodes of intermittent headaches.

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

NEUROLOGICAL:  The patient reports intermittent headaches, denies syncope, dizziness, paralysis, numbness, and tingling of the extremities. He also denied changes in bladder and bwel control.

MUSCULOSKELETAL:  The patient denied muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  He denied anemia, bleeding or bruising.

LYMPHATICS:  He denied enlarged nodes with absence of a history of splenectomy.

PSYCHIATRIC:  He denied history of depression or anxiety.

ENDOCRINOLOGIC:  He denied history of sweating, cold or heat intolerance. He also denied polyuria or polydipsia.

ALLERGIES:  He denied history of asthma, hives, eczema or rhinitis.

O.

Physical exam:

General: The patient appears well groomed, with lack of evidence of weight loss and fatigue

Vitals: Temp 36.7, BP 122/76 P-80, RR 20, SPO2 96,

Head: normocephalic, with no lesions, evidence of trauma, with symmetric facial features. The maxillary and frontal sinuses are tender on palpation.

Ears: The ears are symmetric with absence of ear drainage, loss of balance, and grey tympanic membranes

Eyes: the eyes are symmetric, without jaundice and bleeding. Normal visual acuity

Nose: Absence of nasal flaring, discharge, and septum deviation

Throat: Absence of tonsillitis

Neck: symmetric trachea noted with absence of neck rigidity, swelling, and gross abnormalities of the thyroid

Cardiovascular: presence of S1 and S2, with absence of peripheral edema and advantageous sounds  

Gastrointestinal: Absence of abdominal swelling, scars, with normal bowel movements.

Respiratory: Lung sounds clear with absence of advantageous sounds

Neurological: Client is oriented to self, place, time, and events. Pupil reactive to light and equal in size with equal grip in both hands and symmetrical facial features. The self-reported headache is rated at 8/10. There is the presence of intermittent headache, photophobia, and nausea.

Diagnostic results: One of the recommended diagnostic investigations that should be performed for the client is nasal scrapping. Nasal scraping should be performed to obtain a sample for test for esinophils. Radiological investigations are also recommended in case of severe symptoms. The investigations include a head CT scan to detect any abnormalities such as tissue involvement, inflammation of the meninges, and tumors. A MRI may also be done to determine the presence of any abnormality in the brain tissue and soft tissue pathology. Bacterial sinusitis may also be diagnosed by performing sinus aspiration (Iskandar & Triayudi, 2020).

A.

Differential Diagnoses

Sinusitis: The first differential diagnosis for the client in this case study is sinusitis. Sinusitis is a condition characterized by the inflammation of the nasal cavities. The symptoms often last for a period of less than a month. Patients with sinusitis experience symptoms that include frontal headaches with feelings of fullness. Patients also experience other accompanying symptoms that include nausea, vomiting, photophobia, and nasal drainage. The physical assessment findings may reveal tenderness of the sinuses (Iskandar & Triayudi, 2020). The patient in the case study has symptoms that align with this diagnosis, hence, it being the primary diagnosis.

Migraine headache: migraine headache is the secondary diagnosis for the patient in this case study. Patients with migraine headache experience severe, throbbing headache. The accompanying symptoms include photophobia, phonophobia, nausea, and vomiting (Ha & Gonzalez, 2019). This is however a least diagnosis because of the patient experiencing feelings of fullness and involvement of the sinuses.

Allergic rhinitis: The other possible diagnosis for the client is allergic rhinitis. Patients with allergic rhinitis experience symptoms that include headaches, nasal drainage, coughing, sneezing, and pressure on the cheeks and nose (Scadding et al., 2017). Allergic rhinitis is however the least likely diagnosis due to the absence of a history of allergic reaction by the client.

Facial pain syndrome: Facial pain syndrome is the other potential diagnosis for the client in the case study. Facial pain syndrome is attributed to pain affecting the trigeminal nerve. The symptoms associated with it include pain on touching the face, speaking, chewing or brushing teeth (Benoliel & Gaul, 2017). Facial pain syndrome is however the least likely diagnosis due to the absence of pain upon stimulation of the facial muscles.

Acute bacterial pharyngitis: Acute bacterial pharyngitis is the last potential diagnosis for the client. Acute bacterial pharyngitis is attributed to step bacterial infection. Patients experience symptoms that include difficulty in swallowing, headache, chills, and malaise. The patient however does not experience difficulty in swallowing, fever, and chills, hence, acute bacterial pharyngitis not being the primary differential (Harberger & Graber, 2021).

1.  

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

References

Benoliel, R., & Gaul, C. (2017). Persistent idiopathic facial pain. Cephalalgia, 37(7), 680–691. https://doi.org/10.1177/0333102417706349

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

Harberger, S., & Graber, M. (2021). Bacterial Pharyngitis. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK559007/

Iskandar, A., & Triayudi, A. (2020). Early Diagnosis of Sinusitis Using Expert System Methods: Early Diagnosis of Sinusitis Using Expert System Methods. Jurnal Mantik, 4(2), 1231–1236. https://doi.org/10.35335/mantik.Vol4.2020.927.pp1231-1236

Scadding, G. K., Kariyawasam, H. H., Scadding, G., Mirakian, R., Buckley, R. J., Dixon, T., Durham, S. R., Farooque, S., Jones, N., Leech, S., Nasser, S. M., Powell, R., Roberts, G., Rotiroti, G., Simpson, A., Smith, H., & Clark, A. T. (2017). BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007). Clinical & Experimental Allergy, 47(7), 856–889. https://doi.org/10.1111/cea.12953

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:

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:

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.

1.  

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.

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.

In this Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

To Prepare

• By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
• Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

With regard to the case study you were assigned:

• Review this week’s Learning Resources, and consider the insights they provide about the case study.
• 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.

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.

Week 8: Assessment of the Musculoskeletal System               

Case Study 2

Patient name: Angel Rodriguez Age: 46           Gender: Female         Ethnicity: Hispanic

Angel Rodriguez is a 46-year-old Hispanic female with complaints of pain in both of her ankles, but more pain and concern about the right ankle. She heard a “pop” when she was playing soccer this past weekend. She has the ability to bear weight, but expresses some discomfort.

SUBJECTIVE DATA: 

Chief Complaint (CC): “I have pain in both my ankles, but more in the right.”

History of Present Illness (HPI): AR is a 46 years-old-female who presents to the clinic for bilateral ankle pain for 3 days. The pain started after she was playing soccer over the weekend and noticed a “pop” sound while playing. She reports the pain as “throbbing, sore, and sharp.” She can bear weight on both ankles but the pain is worse on the right. Her pain is a 6/10 on the severity scale. The pain increases to a 9/10 on the right ankle when ambulating or standing for an extended amount of time. AR has been elevating her ankles on pillows and applied heat and ice packs with no relief. She reports her right ankle is swollen and tender to touch. Currently her pain is 3/10 on the left ankle and 8/10 on the right ankle. 

Current Medications

1. Multivitamin PO daily- name unknown
2. Ibuprofen 800 mg Q6 PRN for pain
3. Tylenol 650 mg Q6 PRN for pain

Allergies: 

No drug, food, seasonal, or animal allergies.

Past Medical History (PMH): No recent hospitalizations were reported. Broke left wrist in May 2015. Osteoporosis at age 45. 

Past Surgical History (PSH): No surgery history.

Sexual/Reproductive History: Last menstrual cycle was 3 weeks ago. Engaged to fiance for 8 months. Fiance is AR’s only sexual partner. 

Personal/Social History: AR’s occupation is a Recreational Therapist at University of Chapel Hill (UNC)- Nash for 5 years. Her fiance and her own their home for the past year. They only share their home with 2 dogs. Rodriguez enjoys playing soccer, reading, shopping, and volunteering at her neighborhood garden. She drinks 2-3 glasses of wine every weekend. She denies smoking tobacco/vapes and illicit street drugs. 

Immunization History: 

• Influenza: 09/13/2022. 46 years old.
• Hep B: 3 dose series completed at 6 months old.
• Hep A: 2 dose series completed at 15 months old.
• Pneumococcal: 4 dose series completed at 15 months old.
• DTaP: 5 dose series completed at 6 months old.
• MMR: 2 dose series completed at 6 months old.
• Varicella: 2 dose series completed at 6 months old.
• Polio: 4 dose series completed at 7 months old.

Significant Family History:

• Mother- age 76, DM2, HTN, HLD,
• Father- age 74- tobacco smoker, HTN, COPD
• Maternal Grand-mother- deceased- age 88- CVA
• Maternal Grand-father- deceased- age 86- MI, tobacco smoker, COPD, HTN
• Paternal Grand-mother- age 87- HTN
• Paternal Grandfather- deceased- age 85- CVA

ROS:

• General: Reports feeling fatigued and “extra tired”  from ambulating/bearing weight on her ankles. Reports lack of sleep due to pain. 
• HEENT:

• Head: No headaches reported. Denies dizziness.
• Eyes: Denies problems with eyes.  Denies eye itching, redness, watery or pain. Does wear reading eyeglasses.

• Ears: No history of frequent ear infections. Denies ear surgery history. Denies

ear pain, no swelling or drainage from bilateral ears.  Denies hearing difficulties. Denies ear popping.

• Nose: Denies runny nose, bleeding, or pain. Denies sinus pain.
• Throat: Denies sore throat pain and coughing every few minutes. Denies discolored sputum.
• Cardiovascular: Denies chest pain, tightness, and palpitations
• Respiratory: Denies shortness of breath, wheezing, and cough.
• Musculoskeletal: Denies history of arthritis, limited range of motion. Positive for right ankle swelling, tenderness to touch, pain 9/10. Left ankle full range of motion, no signs of swelling or tenderness, pain 3/10.

Objective:

VS: B/P:120/84 T-98.7 F P-80 R-20 SPO2 -100%RA

Weight: 200 lbs.     

Height: 5’ 8’’ ft

General: AAOx4, cooperative, calm,  appropriate to age.  Able to answer all questions 

appropriately. Appears fatigued and grimaces facial expressions.  

HEENT:

Head: Normal size and shape, hair evenly distributed, no masses.

Cardiovascular/ Peripheral Vascular: S1 and S2 heard on auscultation, no murmurs or extra heart sounds. Right ankle with ecchymosis. edema, tender, and warm to touch. Left ankle no

edema or ecchymosis. Bilateral posterior tibial pulses 2+ No thrill. Bilateral dorsalis pedis 2+ pulses no thrill. Capillary refills in digits and phalanges less than 3 seconds.

Respiratory: Clear breath sounds present in all lung fields. No shortness of breath observed. No posterior/anterior masses, bulges, or crepitus felt on palpation. No adventitious breath sounds on auscultation.

Skin: No lesions, bruises, or bumps. Ecchymosis noted on the right ankle.

Muskuloskeletal: Right ankle edema with 4X4 cm ecchymosis on mid-lateral malleolus area with tenderness upon palpation on the lateral side. Active range of motion with pain bilateral ankles and limitation with dorsiflexion, plantar flexion, and inversion. Positive pain on rotation of ankles bilaterally with worsen pain on right. No bony tenderness, deformity, or crepitus.

Diagnostic Results

X-Ray: Internal/external rotation of bilateral ankles

Anterior/posterior drawing test: applied to assess the integrity of ATFL as it prevents anterior translation of the talus under the distal tibia. Ten millimeters of displacement in the injured ankle or more than 3-4 mm of difference in translation compared with the healthy side indicate an ATFL tear.In an ATFL tear, a dimple sign may also be visible in the anterior side of the joint in 50% of cases anterior and posterior cruciate ligament integrity (Halabchi & Hassabi, 2020)

Talar tilt test: evaluates the integrity of the CFL. In this test, the angle between the talar dome and the tibial plafond is measured during forced heel inversion while the tibiotalar joint is in the neutral position. If there is more than 5° of difference with the normal side, the test is considered positive (Halabchi & Hassabi, 2020)

ASSESSMENT

Angel is having persistent pain in bilateral ankles, more in right than left. With her past medical history of fractured left wrist, there could be an underlying etiology that needs short- term treatment and follow up appointments. With Angel working as a Recreational Therapist and playing soccer for leisure, she is up on her feet the majority of the time. Therefore, diagnosing and treating Angel’s chief complaint is crucial. 

Differential Diagnoses:

1. Ankle fracture- Can be a partial or complete break in the bone. Most likely caused by direct or indirect trauma. Patients can complain of being unable to bear weight at all for extended periods of time, swelling, pain, and limited movement. Felt a “pop” or “snap” with injury (Ball et al., 2019). Site appears swollen, deformity, tender to touch, or deformity.
2. Ankle sprain- Acute ankle sprains are one of the most common musculoskeletal injuries and have a particularly high incidence among physically active individuals (Herzog, 2019). They are most common in athletes. In a typical lateral ankle sprain, ecchymosis and tenderness are located over the ATFL and calcaneofibular (CFL) ligaments (Halabchi & Hassabi, 2020).
3. Tenosynovitis (Tendonitis) – Inflammation of the synovial-lined sheath/affected tendon. Patients can complain of pain, especially with movement. The patient can point to the involved tendon. Pain with active movement and some limitation of movement in the affected joint (Ball et al., 2019).
4. Anterior Ankle Impingement- ankle pain that is caused from consistent dorsiflexion (Tausen et al., 2014). The symptoms of anterior ankle impingement are instability, limited range of motion of the ankle, and pain with any movements (Tausen et al., 2014)
5. Osteoarthritis- deterioration of the articular cartilage covering the end of synovial joints. Onset begins at age 40 and further develops with age. The joints may be enlarged and painful range of motion (Ball et al., 2019).

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.

Halabchi, F., & Hassabi, M. (2020). Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World journal of orthopedics, 11(12), 534.

Herzog, M. M., Kerr, Z. Y., Marshall, S. W., & Wikstrom, E. A. (2019). Epidemiology of ankle sprains and chronic ankle instability. Journal of athletic training, 54(6), 603-610.

Sample Answer for NURS 6512 Case Study Assignment 1 Week 9 Assessing Neurological Symptoms Included

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Week 9 Assignment 1

Week 9: Assessment of Cognition and the Neurologic System

A 63-year-old woman comes to your office because she’s been forgetting things…a young mother comes in concerned because her baby fails to make eye contact and is unresponsive to touch…a teenager comes in and a parent complains that the teen obsessively washes his hands.

An array of neurological conditions could be causing the above symptoms. When assessing the neurologic system, it is vital to formulate an accurate diagnosis as early as possible to prevent continued damage and deterioration of a patient’s quality of life.

This week, you will explore methods for assessing the cognition and the neurologic system.

Learning Objectives

Students will:

• Evaluate abnormal neurological symptoms
• Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for cognition and the neurologic system
• Assess health conditions based on a head-to-toe physical examination

Learning Resources

Required Readings (click to expand/reduce)

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 7, “Mental Status”This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms.

Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: NURS 6512 Case Study Assignment: Assessing Neurological Symptoms

• ·Chapter 23, “Neurologic System”The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings.

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.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 4, “Affective Changes”
This chapter outlines how to identify the potential cause of affective changes in a patient. The authors provide a suggested approach to the evaluation of this type of change, and they include specific tools that can be used as part of the diagnosis.

Chapter 9, “Confusion in Older Adults”
This chapter focuses on causes of confusion in older adults, with an emphasis on dementia. The authors include suggested questions for taking a focused history as well as what to look for in a physical examination.

Chapter 13, “Dizziness”
Dizziness can be a symptom of many underlying conditions. This chapter outlines the questions to ask a patient in taking a focused history and different tests to use in a physical examination.

Chapter 19, “Headache”
The focus of this chapter is the identification of the causes of headaches. The first step is to ensure that the headache is not a life-threatening condition. The authors give suggestions for taking a thorough history and performing a physical exam.

Chapter 31, “Sleep Problems”
In this chapter, the authors highlight the main causes of sleep problems. They also provide possible questions to use in taking the patient’s history, things to look for when performing a physical exam, and possible laboratory and diagnostic studies that might be useful in making the diagnosis.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

• Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5)

Note: Download the Physical Examination Objective Data Checklist to use as you complete the Comprehensive (Head-to-Toe) Physical Assessment assignment.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical examination objective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance Center.

Note: Download and review the Student Checklists and Key Points to use during your practice neurological examination.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Mental status: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Bearden , S. T., & Nay, L. B. (2011). Utility of EEG in differential diagnosis of adults with unexplained acute alteration of mental status. American Journal of Electroneurodiagnostic Technology, 51(2), 92–104.

This article reviews the use of electrocenographs (EEG) to assist in differential diagnoses. The authors provide differential diagnostic scenarios in which the EEG was useful.

Athilingam, P ., Visovsky, C., & Elliott, A. F. (2015). Cognitive screening in persons with chronic diseases in primary care: Challenges and recommendations for practice. American Journal of Alzheimer’s Disease & Other Dementias, 30(6), 547–558. doi:10.1177/1533317515577127

Sinclair , A. J., Gadsby, R., Hillson, R., Forbes, A., & Bayer, A. J. (2013). Brief report: Use of the Mini-Cog as a screening tool for cognitive impairment in diabetes in primary care. Diabetes Research and Clinical Practice, 100(1), e23–e25. doi:10.1016/j.diabres.2013.01.001

Roalf, D. R., Moberg, P. J., Xei, S. X., Wolk, D. A., Moelter, S. T., & Arnold, S. E. (2013). Comparative accuracies of two common screening instruments for classification of Alzheimer’s disease, mild cognitive impairment, and healthy aging. Alzheimer’s & Dementia, 9(5), 529–537. doi:10.1016/j.jalz.2012.10.001. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036230/

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us

Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)

Document: DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment (Word document)

Use this template to complete your Assignment 3 for this week.

Optional Resources

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

• Chapter 14, “The Neurologic Examination” (pp. 683–765)This chapter provides an overview of the nervous system. The authors also explain the basics of neurological exams.

• Chapter 15, “Mental Status, Psychiatric, and Social Evaluations” (pp. 766–786)In this chapter, the authors provide a list of common psychiatric syndromes. The authors also explain the mental, psychiatric, and social evaluation process.

Mahlknecht, P., Hotter, A., Hussl, A., Esterhammer, R., Schockey, M., & Seppi, K. (2010). Significance of MRI in diagnosis and differential diagnosis of Parkinson’s disease. Neurodegenerative Diseases, 7(5), 300–318.

Required Media (click to expand/reduce)

Neurologic System – Week 9 (16m)

Online media for Seidel’s Guide to Physical Examination

It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 7 and 23 that relate to the assessment of cognition and the neurologic system. Refer to the Week 4 Learning Resources area for access instructions on  https://evolve.elsevier.com/

I would rule out Baker’s cyst and patellar chondromalacia as possible diagnoses because these conditions would not cause the patient to experience pain when squatting, jogging, or kicking, as the patient stated. Patellofemoral Joint Syndrome is the most likely cause of knee pain, as it is the most prevalent cause of knee pain in teenagers and is connected with activities that entail repetitive bending, squatting, and running.

This makes Patellofemoral Joint Syndrome the most likely condition. This diagnosis is supported by the fact that the patellar grind test was positive for the patient, who also reported experiencing discomfort when squatting, running, and kicking.

Patellofemoral joint syndrome (PFJS) is a common cause of knee pain in teenagers, particularly in those who participate in activities such as athletics, weightlifting, and taekwondo that involve repetitive bending, squatting, and running. It is brought on by consistent stress and strain placed on the patella and the tissue that surrounds it, which ultimately results in inflammation and pain. The fact that JT experiences discomfort when squatting, jogging, and kicking, in addition to having a positive patellar grind test, makes PFJS the most likely diagnosis in this particular instance.

JT’s Symptoms

PFJS is characterized by discomfort in the front of the knee, which is made worse by movements such as squatting, running, and kicking. This pain is the primary symptom of the condition. A catching sensation under the patella, a grinding sensation when the knee is bent, swelling, and discomfort are some of the additional symptoms that may be present.

JT’s Diagnosis

A physical examination as well as imaging studies such as x-rays, CT scans, and MRIs are typically required to make a diagnosis of PFJS. X-rays are essential for determining whether or not a fracture or dislocation has occurred. If the first diagnosis is favorable, further testing using CT or MRI scans may be performed. The severity of the injury can also be evaluated with the help of other tests, such as the patellar apprehension test, Waldron’s test, Clarke’s test, and eccentric step test.

The primary goals of treatment for PFJS are to reduce inflammation and pain while also attempting to restore normal range of motion. To alleviate pain and inflammation, non-steroidal anti-inflammatory medicines (NSAIDs) like ibuprofen, among others, may be taken as directed. In addition to being essential for regaining strength and range of motion, physical therapy is also very crucial. Exercises that strengthen the quadriceps, glutes, and hamstrings, among other muscle groups, can help stabilize the knee and lessen symptoms of knee instability. Inflammation and soreness can also be alleviated by using ice and getting plenty of rest. In more severe situations, an injection of steroids may be required to treat the condition.

References:

1. American Academy of Orthopaedic Surgeons. (2020). Patellofemoral Joint Syndrome. Retrieved from https://orthoinfo.aaos.org/en/diseases–conditions/patellofemoral-joint-syndrome/
2. Bartz, D. (2020). Patellofemoral Syndrome: Causes, Symptoms, and Treatments. Retrieved from https://www.webmd.com/pain-management/knee-pain/patellofemoral-syndrome#1
3. de Sa, D., & Fonseca, S. (2015). Patellofemoral pain syndrome: Diagnosis and treatment. Brazilian Journal of Physical Therapy, 19(5), 405-413. https://doi.org/10.1590/bjpt-rbf.2014.0090
4. Giza, E., & Fithian, D. C. (2014). Patellofemoral Pain Syndrome: Diagnosis and Management. Journal of the American Academy of Orthopaedic Surgeons, 22(9), 536-544. https://doi.org/10.5435/JAAOS-22-09-536
5. Saxena, A., & Grant, W. (2015). Patellofemoral Pain Syndrome: Pathophysiology, Evaluation, and Management. Journal of the American Academy of Orthopaedic Surgeons, 23(6), 387-395. https://doi.org/10.5435/JAAOS-23-06-387

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Content

Name: NURS_6512_Week_9_Assignment1_Rubric

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		Excellent	Good	Fair	Poor
Using the Episodic/Focused SOAP Template: · 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.		Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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.		Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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.
Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.		Points Range: 5 (5%) – 5 (5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.	Points Range: 4 (4%) – 4 (4%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.	Points Range: 3 (3%) – 3 (3%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.	Points Range: 0 (0%) – 2 (2%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation		Points Range: 5 (5%) – 5 (5%) Uses correct grammar, spelling, and punctuation with no errors.	Points Range: 4 (4%) – 4 (4%) Contains a few (1 or 2) grammar, spelling, and punctuation errors.	Points Range: 3 (3%) – 3 (3%) Contains several (3 or 4) grammar, spelling, and punctuation errors.	Points Range: 0 (0%) – 2 (2%) Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.		Points Range: 5 (5%) – 5 (5%) Uses correct APA format with no errors.	Points Range: 4 (4%) – 4 (4%) Contains a few (1 or 2) APA format errors.	Points Range: 3 (3%) – 3 (3%) Contains several (3 or 4) APA format errors.	Points Range: 0 (0%) – 2 (2%) Contains many (≥ 5) APA format errors.
Total Points: 100

Name: NURS_6512_Week_9_Assignment1_Rubric

Episodic/Focused SOAP Note Template

 

Patient Information:

CH, 32 years old

S.

CC (chief complaint): ‘I have been having a headache for the last one week.’

HPI: The patient is a 40-year-old client that came to the clinic with complaints of headache for one week. The patient reported that she developed a cold three weeks ago. According to her, she believed she was getting better. However, the sinus symptoms are back and even worse. The patient described the headache to be located across her forehead, feeling like pressure behind her eyes, and unable to breathe out of nose. She also reported that she feels mucus running down the back of throat and pain that is sometimes severe (8/10) but acetaminophen reduces it to moderate (4/10) and occasionally mild (2/10). She also reported occasional nonproductive cough, feels feverish at times, and noted frequent sneezing and lack of appetite. Bending over worsened the headache. She also reported that taking Sudafed HCL 120 mg every 12 hours, with some relief. The client further noted that the symptoms are worse in the morning where she awakes with headache, which ranges from 2/10 at its best to 8/10. The symptoms had affected her life and productivity since she reported difficulty in concentrating at job and feels very tired.

Current Medications: The patient currently uses acetaminophen and Sudafed HCL120 mg every 12 hours to manage symptoms.

Allergies: The client denied any known allergy.

PMHx: The client denied any history of surgery or hospital admission. She also denied any history of blood transfusion or chronic illnesses. Soc Hx: The patient is married with one child. She resides in a rented apartment with her family. She works as an accountant. She wears helmet while riding bicycle. She reports that she wears safety belt when driving.

Fam Hx: The client denied any history of chronic illnesses in the family.

ROS:

GENERAL:  The client was dressed appropriately for the occasion. She denied weight gain, fatigue, and cold intolerance. She reports occasional fevers and no chills.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss. She reports sneezing, congestion and runny nose. She reports feeling mucus draining behind her back of the throat. She denies sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. Reports decrease in appetite.

GENITOURINARY:  Denies burning on urination. Her last menstrual period was 20/01/2023.

NEUROLOGICAL:  The patient reports sinus headache and feels the sinuses are full. Denies dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Reports cold intolerance. No polyuria or polydipsia.

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

O.

Physical exam:

Neurological: The patient rates headache 8/10 in pain rating scale. There is normal muscle tone, strength, and movement of joints in range of motion. No paresthesia, loss of body balance, and tremors. Tender paranasal sinuses on palpation. 

Nose and throat: Presence of rhinorrhea and mucosal edema, no lymphadenopathy, with no nasal flaring, inflamed adenoids, and halitosis.

Diagnostic results: sinus x-ray was requested to assess frontal, maxillary, and sphenoid sinuses for their involvement. The results revealed air-fluid levels and mucosal thickening. In complex cases, CT scan is requested to come up with an accurate diagnosis. Culture was taken to determine the cause of sinusitis.

A.

Differential Diagnoses

Sinusitis: Sinusitis is the client’s primary diagnosis. Sinusitis is an acute infection tht is largely attributed to viral cause and bacterial causes in some cases. Patients develop symptoms secondary to the inflammation and edema of the nasal lining. There is also the production of thick mucus that cause paranasal sinuses obstruction and thriving of bacteria. Bacterial sinusitis follows a case of viral upper respiratory tract infection (Kim, 2019). Patients affected by sinusitis present with a range of symptoms. They include facial pressure or pain, facial fullness, nasal or postnasal purulence, nasal obstruction, fever, and hyposmia. Patients may also complain of halitosis, headache, dental pain, malaise, cough, and otalgia (Bernichi et al., 2021). Physical examinations findings may reveal facial swelling or erythema, postnasal drainage, cervical adenopathy, or pharyngitis. Rhinoscopy may show mucous crusting, obstructive polyps, and mucosal edema (Battisti et al., 2022). The patient in the case study has symptoms that align with those of sinusitis. The patient has a history of cold, which may have contributed to the development of the symptoms. She also reports headache, fever, post-nasal drainage, and worsening sinus symptoms. As a result, sinusitis is her primary diagnosis.

Upper respiratory tract infection: upper respiratory tract infection is the other diagnosis that should be considered for the client. Upper respiratory tract infections affect pharynx, larynx, nose, and throat. Patients experience a range of symptoms that include cough, study nose, sneezing, and sore throat. They may also have cough, fever, dysphagia, malaise, and myalgias. These symptoms are closely related to those of sinusitis. As a result, it is crucial to perform additional investigations such as sinus x-ray and cultures to determine the potential cause of the problem (Thomas & Bomar, 2022). In addition, rapid strep swabs may be needed to rule out bacterial pharyngitis.

Tension headache: Tension headache is the other potential diagnosis that should be considered for the client. The headache is characterized by feelings of tension pressure around the head (Steel et al., 2021). Factors such as poor posture, tiredness, stress, tension, and emotional stress cause tension headaches. The associated symptoms include bilateral dull ache, and tightness or aches in the shoulders and neck (Haratian et al., 2020). However, tension headache is the least likely diagnosis for this client. This is because of the presence of additional symptoms such as nasal fullness, postnasal drainage, fever, and changes in appetite, which are not associated with tension headaches.

 

P.  

References

Battisti, A. S., Modi, P., & Pangia, J. (2022). Sinusitis. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK470383/

Bernichi, J. V., Rizzo, V. L., Villa, J. F., Santos, R. F., & Caparroz, F. A. (2021). Rhinogenic and sinus headache – Literature review. American Journal of Otolaryngology, 42(6), 103113. https://doi.org/10.1016/j.amjoto.2021.103113

Haratian, A., Amjadi, M. M., Ghandehari, K., Hatamian, H., Kiani, S., Habibi, M., Aghababaei, Z., & Ataei, M. (2020). Emotion regulation difficulties and repetitive negative thinking in patients with tension headaches and migraine. Caspian Journal of Neurological Sciences, 6(3), 147–155. https://doi.org/10.32598/CJNS.6.22.3

Kim, S. M. (2019). Definition and management of odontogenic maxillary sinusitis. Maxillofacial Plastic and Reconstructive Surgery, 41(1), 13. https://doi.org/10.1186/s40902-019-0196-2

Steel, S. J., Robertson, C. E., & Whealy, M. A. (2021). Current understanding of the pathophysiology and approach to tension-type headache. Current Neurology and Neuroscience Reports, 21(10), 56. https://doi.org/10.1007/s11910-021-01138-7

Thomas, M., & Bomar, P. A. (2022). Upper respiratory tract infection. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK532961/