Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Demographic Data
Initials: S.K.
Sex: Male
Age: 20
Race: African
Subjective Data:
Chief Complaint: intermittent headaches
History of Present Illness: the patient is a 20-year-old who presented with complaints of sudden onset intermittent headaches that have now lasted six weeks.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
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Location: Head, above the eyes and spreads through the nose, cheekbones, and the jaws
Onset: in the last six weeks
Character: was of sudden onset, intermittent and diffuse all over the head, throbbing in nature
Associated signs and symptoms: loss of appetite, vomiting, and nausea, and fatigue, increased sensitivity to light
Timing: most severe in the morning but occurs throughout the day.
Exacerbating Factors: none
Relieving factors: oral Ibuprofen
Severity: Pain scale rated 8/10
Current Medications: Ibuprofen 400mg PO q6-8hrs-provides mild relief
Allergies: none
Past Medical History (PMH): patient-reported similar incidences of intermittent headaches six months ago. However, the headaches resolved with no medical intervention. He also reported having low-blood pressure two months ago. His immunizations were up to date and his last annual physical exam was four months ago.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Social History (Soc Hx): a student in college pursuing business administration. Part-time, he manages their family’s farm to gain more experience as an administrator and manager. He is currently single, lives with his younger sister (16 years), father, and mother. He has an interest in basketball which he plays in his free time. He is a non-smoker, does not take alcohol, recreational or illegal drugs. He also observes personal safety by wearing a seat belt and not using his cell phone when driving. He however acknowledged regularly taking caffeinated beverages such as soda and coffee (4-5 times daily).Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Family History (Fam Hx): his mother and father are both alive. His father has hypertension and his mother has type 2 Diabetes mellitus. His younger sister has no medical issues.
Review of System (ROS):
Constitutional: denies weight loss, chills, night sweats, and fevers,
HEENT: denies double vision or blurred vision, visual loss, yellow sclera, denies loss in hearing, sneezing, congestion, sore throat, runny nose, pain in swallowing.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Skin: denies itching, lesions, rashes, or allergy
Cardiovascular: denies chest pain, palpitations, edema, or chest pressure.
Respiratory: denies cough, shortness of breath, sputum production, and sinus problems
Gastrointestinal: reports occasional vomiting and nausea, denies anorexia, diarrhea, changes in bowel habits, and abdominal pain.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Genitourinary: denied burning on urination, dysuria, urgency, frequency, or hematuria
Neurological: denied ataxia, paralysis, tingling or numbness in the extremities, dizziness, syncope, no changes in bladder or bowel control
Musculoskeletal: denied muscle pain, joint pain, stiffness, and swellings
Hematologic: denied bleeding, bruising, a blood disorder, or anemia
Lymphatic: denied enlarged nodes, denied undergoing splenectomy
Psychiatric: denied depression, anxiety, suicidal and homicidal ideation, but acknowledged being stressed due to low grades in school in his past exam
Endocrinologic: denied heat or cold intolerance, denied polyuria and polydipsia.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Allergies: denied eczema, hives, asthma, and rhinitis.
Objective Data:
Vital Signs:
Height: 5’7’’
Weight: 145 pounds
Temperature: 99.7
Heart rate: 75
Respiratory rate: 17
Blood Pressure: 129/70
Physical Examination:
General: a healthy and well-groomed and nourished 20-year-old male AOX4spheres in no acute distress
Skin: warm and dry with no diaphoresis.
HEENT: atraumatic, normocephalic, mildly tender temporal arteries on palpation, non-tender maxillary and frontal sinuses, symmetrical tongue, PEBRL.
Visual acuity– LE- 20/20, RE-20/40
Left funduscopic exam: disc margins have no hemorrhages and are sharp
Right fundoscopic exam: intact bilateral extraocular movements with a normal convergence, no retinopathic changes Symmetric and intact facial sensation, bilaterally normal Rinne and Weber tests, intact gag reflex. Nose is symmetric and intact sense of smell, the patient can symmetrically shrug shoulders, the patient has a strength of 5 against resistance, neck has a FROM against resistance.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
CNS: the patient is alert and oriented in Time, Place, and Person and maintained eye contact throughout the interview and exam
Musculoskeletal: Upper and lower extremities DTRs 2+ and equal bilaterally, smooth point-to-point movements, heel-to shin, and finger-to-nose movements are accurate, upper extremities movements are bilaterally intact and alternating rapidly, graphesthesia, and stereognosis bilaterally intact, the patient has a steady gait with symmetric and continuous steps, intact sense of extremity position and sensation of both the lower and upper limbs.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Diagnostic Measures
To make a specific diagnosis, it will be appropriate to order the following diagnostic tests:
Complete Blood Count (CBC):
A CBC can help to determine possible differentials such as malfunctioning or low RBCs which can cause anemia whose one presenting symptom is headaches, elevated or low WBC count as a sign of infection (bacterial meningitis) in a patient presenting with a complaint of headaches, or a possible low platelet count (Evans, 2019).
Erythrocyte Sedimentation Rate (ESR):
An ESR is important to detect inflammation and evaluate patients presenting with headaches for possible giant cell arteritis
CT scan: a head CT scan can help the clinician to rule out or diagnose other potential causes of a headache such as a brain tumor or blockage of a sinus (Kuruvilla & Lipton, 2015). Ophthalmoscopy: ophthalmoscopy helps a clinician to identify any ophthalmic vascular, inflammatory, neurologic, and mechanical mechanisms that can cause headaches.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Differential Diagnosis
Tension-type Headache: It is important to include this differential diagnosis since it has the following clinical features: a patient will report a history of infrequent to frequent episodes of bilateral mild-moderate non-pulsating, intermittent, tightening, or pressing cephalgia. This can be associated with either phonophobia or photophobia but no associations with nausea or vomiting (Semenov, 2015). The progression and pattern of tension headaches are that they can last for 30minutes-7 days but the pain is not aggravated by activities such as climbing or walking. On physical exam, the clinician may find the tenderness of the pericranial muscles.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Migraine: Migraine is also a likely differential. One of its major risk factors is increased intake of caffeinated beverages and soda. Migraine headaches last for about 4-72 hours with associated symptoms of vomiting, nausea, anorexia, and food intolerance (Gazerani, 2020). The pain is often pulsating or throbbing in nature with either localized or unilateral pain in the ocular or frontotemporal areas which worsen/aggravate with physical activity or movement.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Brain Tumor: A brain tumor may also be possible differential diagnoses whose common presenting signs are sudden onset intermittent headaches due to increased intracranial pressure following obstruction of in the flow of the CSF (Hadidchi et al., 2019).
Giant Cell Arteritis: Giant cell arteritis occurs commonly among adults aged 50 years and older although it can also occur in young individuals aged 20 years and older (Peral-Cagigal et al., 2018).The main signs and symptoms that patients present with include a history of persistent moderate-severe temporal headaches, tenderness on the scalp areas, jaw pain, myalgia, diplopia, unilateral or sudden vision loss, and systemic symptoms of unexplained weight loss, fevers, nausea, and fatigue.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Sinusitis: sinusitis is also a probable diagnosis of for this patient. Patients may report a throbbing headache that may last for several days or even longer lasting two hours daily or more. According to Rosenfeld (2016), patients may also report fatigue, a decreased sense of taste accompanied with nasal symptoms such as nasal congestion, obstruction inflammation, facial pressure, or facial pain
Demographic Data
Initials: S.K.
Sex: Male
Age: 20
Race: African
Subjective Data:
Chief Complaint: intermittent headaches
History of Present Illness: the patient is a 20-year-old who presented with complaints of sudden onset intermittent headaches that have now lasted six weeks
Location: Head, above the eyes and spreads through the nose, cheekbones, and the jaws
Onset: in the last six weeks
Character: was of sudden onset, intermittent and diffuse all over the head, throbbing in nature
Associated signs and symptoms: loss of appetite, vomiting, and nausea, and fatigue, increased sensitivity to light
Timing: most severe in the morning but occurs throughout the day.
Exacerbating Factors: none
Relieving factors: oral Ibuprofen
Severity: Pain scale rated 8/10
Current Medications: Ibuprofen 400mg PO q6-8hrs-provides mild relief
Allergies: none
Past Medical History (PMH): patient-reported similar incidences of intermittent headaches six months ago. However, the headaches resolved with no medical intervention. He also reported having low-blood pressure two months ago. His immunizations were up to date and his last annual physical exam was four months ago.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Social History (Soc Hx): a student in college pursuing business administration. Part-time, he manages their family’s farm to gain more experience as an administrator and manager. He is currently single, lives with his younger sister (16 years), father, and mother. He has an interest in basketball which he plays in his free time. He is a non-smoker, does not take alcohol, recreational or illegal drugs. He also observes personal safety by wearing a seat belt and not using his cell phone when driving. He however acknowledged regularly taking caffeinated beverages such as soda and coffee (4-5 times daily).Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Family History (Fam Hx): his mother and father are both alive. His father has hypertension and his mother has type 2 Diabetes mellitus. His younger sister has no medical issues.
Review of System (ROS):
Constitutional: denies weight loss, chills, night sweats, and fevers,
HEENT: denies double vision or blurred vision, visual loss, yellow sclera, denies loss in hearing, sneezing, congestion, sore throat, runny nose, pain in swallowing.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Skin: denies itching, lesions, rashes, or allergy
Cardiovascular: denies chest pain, palpitations, edema, or chest pressure.
Respiratory: denies cough, shortness of breath, sputum production, and sinus problems
Gastrointestinal: reports occasional vomiting and nausea, denies anorexia, diarrhea, changes in bowel habits, and abdominal pain.
Genitourinary: denied burning on urination, dysuria, urgency, frequency, or hematuria
Neurological: denied ataxia, paralysis, tingling or numbness in the extremities, dizziness, syncope, no changes in bladder or bowel control
Musculoskeletal: denied muscle pain, joint pain, stiffness, and swellings
Hematologic: denied bleeding, bruising, a blood disorder, or anemia
Lymphatic: denied enlarged nodes, denied undergoing splenectomy
Psychiatric: denied depression, anxiety, suicidal and homicidal ideation, but acknowledged being stressed due to low grades in school in his past exam
Endocrinologic: denied heat or cold intolerance, denied polyuria and polydipsia.
Allergies: denied eczema, hives, asthma, and rhinitis.
Objective Data:
Vital Signs:
Height: 5’7’’
Weight: 145 pounds
Temperature: 99.7
Heart rate: 75
Respiratory rate: 17
Blood Pressure: 129/70
Physical Examination:
General: a healthy and well-groomed and nourished 20-year-old male AOX4spheres in no acute distress
Skin: warm and dry with no diaphoresis.
HEENT: atraumatic, normocephalic, mildly tender temporal arteries on palpation, non-tender maxillary and frontal sinuses, symmetrical tongue, PEBRL.
Visual acuity– LE- 20/20, RE-20/40
Left funduscopic exam: disc margins have no hemorrhages and are sharp
Right fundoscopic exam: intact bilateral extraocular movements with a normal convergence, no retinopathic changes Symmetric and intact facial sensation, bilaterally normal Rinne and Weber tests, intact gag reflex. Nose is symmetric and intact sense of smell, the patient can symmetrically shrug shoulders, the patient has a strength of 5 against resistance, neck has a FROM against resistance.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
CNS: the patient is alert and oriented in Time, Place, and Person and maintained eye contact throughout the interview and exam
Musculoskeletal: Upper and lower extremities DTRs 2+ and equal bilaterally, smooth point-to-point movements, heel-to shin, and finger-to-nose movements are accurate, upper extremities movements are bilaterally intact and alternating rapidly, graphesthesia, and stereognosis bilaterally intact, the patient has a steady gait with symmetric and continuous steps, intact sense of extremity position and sensation of both the lower and upper limbs.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Diagnostic Measures
To make a specific diagnosis, it will be appropriate to order the following diagnostic tests:
Complete Blood Count (CBC):
A CBC can help to determine possible differentials such as malfunctioning or low RBCs which can cause anemia whose one presenting symptom is headaches, elevated or low WBC count as a sign of infection (bacterial meningitis) in a patient presenting with a complaint of headaches, or a possible low platelet count (Evans, 2019). Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Erythrocyte Sedimentation Rate (ESR):
An ESR is important to detect inflammation and evaluate patients presenting with headaches for possible giant cell arteritis
CT scan: a head CT scan can help the clinician to rule out or diagnose other potential causes of a headache such as a brain tumor or blockage of a sinus (Kuruvilla & Lipton, 2015). Ophthalmoscopy: ophthalmoscopy helps a clinician to identify any ophthalmic vascular, inflammatory, neurologic, and mechanical mechanisms that can cause headaches.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Differential Diagnosis
Tension-type Headache: It is important to include this differential diagnosis since it has the following clinical features: a patient will report a history of infrequent to frequent episodes of bilateral mild-moderate non-pulsating, intermittent, tightening, or pressing cephalgia. This can be associated with either phonophobia or photophobia but no associations with nausea or vomiting (Semenov, 2015). The progression and pattern of tension headaches are that they can last for 30minutes-7 days but the pain is not aggravated by activities such as climbing or walking. On physical exam, the clinician may find the tenderness of the pericranial muscles.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
Migraine: Migraine is also a likely differential. One of its major risk factors is increased intake of caffeinated beverages and soda. Migraine headaches last for about 4-72 hours with associated symptoms of vomiting, nausea, anorexia, and food intolerance (Gazerani, 2020). The pain is often pulsating or throbbing in nature with either localized or unilateral pain in the ocular or frontotemporal areas which worsen/aggravate with physical activity or movement.
Brain Tumor: A brain tumor may also be possible differential diagnoses whose common presenting signs are sudden onset intermittent headaches due to increased intracranial pressure following obstruction of in the flow of the CSF (Hadidchi et al., 2019).
Giant Cell Arteritis: Giant cell arteritis occurs commonly among adults aged 50 years and older although it can also occur in young individuals aged 20 years and older (Peral-Cagigal et al., 2018).The main signs and symptoms that patients present with include a history of persistent moderate-severe temporal headaches, tenderness on the scalp areas, jaw pain, myalgia, diplopia, unilateral or sudden vision loss, and systemic symptoms of unexplained weight loss, fevers, nausea, and fatigue.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
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.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
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. (provide at least 5 differential diagnoses with rationales for each diagnosis)
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 9-Case Study Assignment: Assessing Neurological Symptoms.
CASE STUDY 1: Headaches
A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.Week 9-Case Study Assignment: Assessing Neurological Symptoms.
