Case Study Assignment: Assessing Neurological Symptoms

Case Study Assignment: Assessing Neurological Symptoms

Assessing Neurological Symptoms

Patient Information:

R.R., 47 years, Male, African American

S.

CC (chief complaint) ‘headache’

HPI: R.R. is a 47-year-old African-American male who came to the facility with complaints of headaches for the last ten days. The patient reports that the headaches diffuse all over his head but the greatest intensity and pressure occur above the eyes and spread through the nose, jaw, and cheekbones. The patient described the pain as dull, with intense pressure. The associated symptoms include nausea. The onset of the headache varies. He reported that taking Tylenol and avoiding strenuous activities relieve the headaches. He rates pain severity as 7/10 on the pain rating scale.

Current Medications: R.R. reported that he has been taking oral Tylenol 1gm thrice daily for the headaches. He denied any other current use of medications.

Allergies: R.R. reported seasonal allergies. He is also allergic to penicillin. He developed acute respiratory distress the last time he was administered with penicillin at the age of 11 years old. He denied food allergies.

PMHx: R.R. was admitted to the hospital at the age of 35 due to pneumonia. He underwent an appendectomy 10 years ago. His immunization record is up-to-date.

Soc Hx: R.R. is a truck driver. He is married with three children. He lives with his spouse and one child in a rented apartment. His other children are in college. R.R. reports that he stopped taking alcohol ten years ago. He denied tobacco use. R.R. engages regularly in active physical activities. He uses seat belts when driving. They live in a clean community.

Fam Hx: R.R.’s grandfather died of coronary artery disease. His grandmother, aged 90 years has dementia. His wife has controlled hypertension. His mother died of breast cancer.

ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, or sore throat. Reports rhinorrhea for the last five days

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.

GENITOURINARY:  Denies burning on urination, urgency, and frequency

NEUROLOGICAL:  Reports dull headache. He 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 a history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Reports seasonal allergies.

O.

Physical exam:

Vitals: BP 127/82, P 84, RR 21, T 99.9F, SPO2 96% room air,

General: R.R. is dressed appropriately for the occasion. He is alert and oriented to himself, time, others, and events. He denies chills, fever, and fatigue.

HEENT: Head: The head is atraumatic with normal hair distribution. There are no altered facial features such as drooping and tremors. Frontal sinuses tender to palpation. Ears: Ears are symmetric, with no erythema and bulging tympanic membranes. Eyes: The sclera is clear with no discharge and normal pupil reaction to light. Nose: There is mild rhinorrhea with no nasal flaring, septum deviation, or crusts. Throat: There is no tonsillitis or exudate. There is post-nasal drainage. Neck: There is no neck rigidity, masses, or webbing.

Cardiovascular: There are regular heart rate and rhythm with no adventitious heart sounds and peripheral edema.

Respiratory: There are clear lung sounds over all fields with no adventitious sounds

Neurological: R.R. responds appropriately to the questions asked. He is alert and oriented to himself, others, time, place, and event. His pupils reach equally to light. He has equal grip strength. His balance and posture are normal. He reports a headache rated at 7/10 on a pain rating scale. He denies photophobia, nausea, and vomiting.

Diagnostic results: A nasal smear is needed to determine if the patient has allergic rhinitis based on the presence or absence of eosinophils. A radiograph such as a head CT scan may be needed if the symptoms do not respond to the prescribed treatment. Sinus aspiration may be needed to determine if the patient has bacterial sinusitis.

A.

Differential Diagnoses

Sinusitis: Sinusitis is R.R.’s primary diagnosis. Sinusitis refers to an inflammation of the nasal cavities. Sinusitis develops from causes such as bacterial and viral infections and exposure to allergens. Patients often complain of frontal headaches, feelings of fullness, ear pain, fever, cough, bad breath, stuffy nose, runny nose, and tiredness. Physical examination findings include the presence of a postnasal drip and sinus tenderness (Craig et al., 2021; Psillas et al., 2021; Wyler & Mallon, 2019). R.R.’s symptoms align with those seen in sinusitis, hence, the primary diagnosis.

Migraine headache: Migraine headache is the other differential that should be considered for R.R. Patients with migraine headaches complain of severe throbbing headaches accompanied by symptoms such as vomiting, nausea, and light sensitivity. The pain is so severe that it interferes with the patient’s daily functioning. The additional symptoms seen among patients with migraine headaches include frequent yawning, increased urination, mood changes, aura, and confusion during the post-drome period (Ghorbani et al., 2019; Ghoreishy et al., 2022; Ha & Gonzalez, 2019). Despite R.R. reporting headaches, there are no other symptoms such as photophobia, which rules out migraine headaches as his problem.

Allergic rhinitis: Allergic rhinitis is the other differential that should be considered for R.R. Allergic rhinitis is a condition characterized by the inflammation of the nasal cavities. It develops following exposure to allergens such as dust and pollen. Patients often experience flu-like symptoms such as itchiness, sneezing, runny and blocked nose. The symptoms are always mild and resolve on their own (Bousquet et al., 2020; Zhang et al., 2021). Despite R.R. having symptoms such as a runny nose, allergic rhinitis is the least likely cause of his problems.

Tension headache: Tension headache is the other differential diagnosis to be considered for the patient. Tension headaches have a characteristic of pain described as a tight band all over the head (Burch, 2019). Patients also have scalp, neck, and shoulder muscle tenderness.

Brain abscess: Brain abscess is the other diagnosis to be considered for the patient. It develops from bacterial or fungal infection of the brain tissue (Corsini Campioli et al., 2021). The symptoms that patients experience include a fever, headache, neck rigidity, and seizures, which are not evident in the patient’s case.

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

References

Bousquet, J., Anto, J. M., Bachert, C., Baiardini, I., Bosnic-Anticevich, S., Walter Canonica, G., Melén, E., Palomares, O., Scadding, G. K., Togias, A., & Toppila-Salmi, S. (2020). Allergic rhinitis. Nature Reviews Disease Primers, 6(1), Article 1. https://doi.org/10.1038/s41572-020-00227-0

Burch, R. (2019). Migraine and Tension-Type Headache: Diagnosis and Treatment. Medical Clinics, 103(2), 215–233. https://doi.org/10.1016/j.mcna.2018.10.003

Corsini Campioli, C., Castillo Almeida, N. E., O’Horo, J. C., Esquer Garrigos, Z., Wilson, W. R., Cano, E., DeSimone, D. C., Baddour, L. M., Van Gompel, J. J., & Sohail, M. R. (2021). Bacterial Brain Abscess: An Outline for Diagnosis and Management. The American Journal of Medicine, 134(10), 1210-1217.e2. https://doi.org/10.1016/j.amjmed.2021.05.027

Craig, J. R., Poetker, D. M., Aksoy, U., Allevi, F., Biglioli, F., Cha, B. Y., Chiapasco, M., Lechien, J. R., Safadi, A., Simuntis, R., Tataryn, R., Testori, T., Troeltzsch, M., Vaitkus, S., Yokoi, H., Felisati, G., & Saibene, A. M. (2021). Diagnosing odontogenic sinusitis: An international multidisciplinary consensus statement. International Forum of Allergy & Rhinology, 11(8), 1235–1248. https://doi.org/10.1002/alr.22777

Ghorbani, Z., Togha, M., Rafiee, P., Ahmadi, Z. S., Rasekh Magham, R., Haghighi, S., Razeghi Jahromi, S., & Mahmoudi, M. (2019). Vitamin D in migraine headache: A comprehensive review on literature. Neurological Sciences, 40(12), 2459–2477. https://doi.org/10.1007/s10072-019-04021-z

Ghoreishy, S. M., Askari, G., Mohammadi, H., Campbell, M. S., Khorvash, F., & Arab, A. (2022). Associations between potential inflammatory properties of the diet and frequency, duration, and severity of migraine headaches: A cross-sectional study. Scientific Reports, 12(1), Article 1. https://doi.org/10.1038/s41598-022-06819-y

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

Psillas, G., Papaioannou, D., Petsali, S., Dimas, G. G., & Constantinidis, J. (2021). Odontogenic maxillary sinusitis: A comprehensive review. Journal of Dental Sciences, 16(1), 474–481. https://doi.org/10.1016/j.jds.2020.08.001

Wyler, B., & Mallon, W. K. (2019). Sinusitis Update. Emergency Medicine Clinics, 37(1), 41–54. https://doi.org/10.1016/j.emc.2018.09.007

Zhang, Y., Lan, F., & Zhang, L. (2021). Advances and highlights in allergic rhinitis. Allergy, 76(11), 3383–3389. https://doi.org/10.1111/all.15044

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