NURS 6512 Case Study Assignment: Assessing Neurological Symptoms

NURS 6512 Case Study Assignment: Assessing Neurological Symptoms

NURS 6512 Case Study Assignment: Assessing Neurological Symptoms

Patient Information:

B.B., 22 years old, African America female

S.

CC (chief complaint): “Facial drooping”

HPI: The client is a 22-year-old African American female who visited the facility with complaints of facial drooping. The patient reports that she noticed facial drooping while looking at herself in the mirror. She noted that the left side of her mouth is slanted when she smiles. She also reported some headaches off and on for a few days. The patient’s sense of taste has decreased. She felt the decrease when brushing her teeth.

Current Medications: The patient denied any current use of medications.

Allergies: The patient reports that she is allergic to penicillin. She develops a cough and wheezing when she takes penicillin-containing medications. She also reported a history of seasonal allergies.

PMHx: The client reports that she was hospitalized when she was 18 years old because of meningitis. She denied any history of surgeries. She also denied any other history of chronic illnesses.
Soc & Substance Hx: The patient is a university student. She is majoring in business and finance. She reports that she takes alcohol occasionally. She does not smoke or use illegal substances. She is the only child in her family. The patient lives with her parents in a rented apartment. The patient spends her leisure time with her friends, reading, or visiting new places. She wears a seat belt when driving and a helmet when riding a bicycle. The client denies being in any relationship. Their home has smoke detectors.

Fam Hx:

Her mother has asthma, diabetes, and hypertension

Her father smokes, has hypertension, and is obese

Her grandfather has heart disease

Her grandmother has dementia

Surgical Hx: The client denied any history of surgical procedures

Mental Hx: Diagnosis and treatment. Current concerns: The client reports that she has never been diagnosed or started treatment for mental health problems such as major depression or anxiety.

Reproductive Hx: The client reports that her menarche started when she was 13 years old. She has a regular menstrual cycle that occurs after every 28-32 days and lasts 4-5 days. She denies any problems with her menstrual cycle. The client has never been pregnant. She has a history of contraceptive use. She denies being in any relationship currently. The client reports that she prefers sexual relationships with men. She engages in vaginal sex. She denies a history of sexually transmitted infections. The patient denies urgency, frequency, or dysuria.

ROS:

GENERAL: The client is dressed appropriately for the occasion. She denies fever, weight loss, or chills. There is evident facial drooling on the left side.

HEENT: Eyes: The client does not wear corrective lenses. She reports left eye dryness due to the facial drooping problem. She cannot close the left eyelid. She denies eye pain, drainage, or blurred vision. Ears, Nose, Throat: She denies changes in hearing, sneezing, nasal congestion, or a sore throat.

SKIN: She denies itchiness, skin rash, or abnormal findings on her self-breast examination.

CARDIOVASCULAR: The client reports no experiences of chest pain, discomfort, or palpitations

RESPIRATORY: The client denies any experiences of cough, difficulty breathing, wheezing, or sputum production

GASTROINTESTINAL: The client reports a decreased sensation of taste. She denies  nausea, vomiting, diarrhea, or abdominal pain

NEUROLOGICAL: The client reports left-side facial drooping. She denies syncope, loss of consciousness, changes in her bladder and bowel control, loss of balance, or difficulty coordinating movements

MUSCULOSKELETAL: The client denies muscle or joint pain, inflammation, stiffness, or decreased range of motions

HEMATOLOGIC: The client denies easy bruising or a history of anemia.

LYMPHATICS: The client reports that she has no history of lymph node surgical removal. She denies lymphadenopathy.

PSYCHIATRIC: The client denies a history of mental health disorders such as depression and anxiety

ENDOCRINOLOGIC: The client denies experiencing heat or cold intolerance. She also denies diabetes-related symptoms such as polyuria, polyphagia, or polydipsia.

GENITOURINARY: The client denies urinary leakage, dysuria, urinary frequency or urgency

ALLERGIES: MA is allergic to penicillin and has seasonal allergies

O.

Physical exam:

Vitals: BP 108/70, P 72, T 99.1, RR 20, SPO2 98%

Respiratory system: There is no wheezing, cough, sputum production, dyspnea, or respiratory distress

Cardiovascular system: Presence of S1 and S2 heart sounds. Absence of S3 and S4 heart sounds and peripheral edema

Skin: There is left-sided facial drooping. There is increased pain sensitivity when the affected side is touched.

Neurological: There is left-sided facial drooping. There is increased pain sensitivity to touch on the affected side. The client is unable to close the left eyelid. There is no syncope, decreased level of consciousness, or balance and gait problems

Diagnostic results: Nerve conduction test and electromyography should be performed to determine nerve involvement and its severity. The studies will also provide insights into the prognosis of the client’s problem. A complete blood count should also be performed to rule out causes such as viruses. A blood test for Lyme disease should also be conducted. Ophthalmic examination should be performed to determine eyelid position, orbicularis strength, and lagophthalmos (Singh & Deshmukh, 2022). The additional laboratory investigations that should be done include a syphilis screen, erythrocyte sedimentation rate, and C-reactive protein tests.

A.

Primary and Differential Diagnoses

Bell’s palsy: Bell’s palsy is the client’s primary diagnosis. Bell’s palsy is a condition that develops from the inflammation of cranial nerve VII. Bell’s palsy is characterized by symptoms that include partial or total unilateral paralysis, facial droop, drooling, asymmetric smile, and poor eyelid closure. Other symptoms that patients might experience include a loss of taste, jaw pain, sensitivity to sound on the affected side, and headache (Singh & Deshmukh, 2022; Zhang et al., 2020). The client in the case study has these symptoms, hence, Bell’s palsy is her primary diagnosis.

Stroke: Stroke is one of the differential diagnoses that should be considered. Stroke is a neurological disorder that develops from inadequate blood supply to the brain. It develops from causes associated with either bleeding to the brain or occlusion of the blood supply. Patients experience symptoms such as paralysis, difficulty speaking, unilateral numbness, headache, and difficulty walking among others (Murphy & Werring, 2020; Powers, 2020). Stroke is the least likely diagnosis because of the absence of symptoms such as difficulty speaking and walking in the client.

Cerebellopontine angle tumor: Cerebellopontine angle tumor is the other diagnosis that should be considered for the patient. The tumor affects the housing of cranial nerves V, VI, VII, and VII and blood vessels, including the anterior inferior cerebellar artery (Lak & Khan, 2023). Patients experience symptoms such as tinnitus, hearing loss, headaches, vertigo, gait dysfunction, and facial drooping, which are not evident in the case study.

Lyme disease: Lyme disease is the other differential to be considered for the patient. Lyme disease is a tick-borne condition that is associated with symptoms, including headache, fever, fatigue, and skin rash. It can also be associated with numbness, facial palsy, and visual disturbances (Coburn et al., 2021; Mead, 2022). Lyme disease is the least likely cause of the client’s problem because of the absence of fever, fatigue, and skin rashes.

Different diagnostic and laboratory investigations such as nerve conduction tests and Lyme antibody tests should be performed. The patient should be educated on the importance of using artificial tears, chewing on the unaffected side, engaging in facial exercises, treatment adherence, and covering the affected eye to prevent trauma. The patient should also be educated on the importance of wearing glasses or goggles to prevent dust or dirt from the affected eye. She should also be encouraged to maintain oral hygiene to prevent tooth infections. She should also be educated on the importance of remaining adequately hydrated and avoiding alcohol-containing products, which will dry her oral mucosa (Mustafa & Suleiman, 2020; Singh & Deshmukh, 2022). I agree with the preceptor’s diagnosis since the client’s complaints do not show an underlying pathology such as stroke or malignancy. I learned about the importance of a comprehensive neurological exam to rule out potential diagnoses of Bell’s palsy. I will investigate the impact of Bell’s palsy on the client’s functioning and quality of life should I experience a similar case in the future.

References

Coburn, J., Garcia, B., Hu, L. T., Jewett, M. W., Kraiczy, P., Norris, S. J., & Skare, J. (2021). Lyme Disease Pathogenesis. Current Issues in Molecular Biology, 42(1), Article 1. https://doi.org/10.21775/cimb.042.473

Lak, A. M., & Khan, Y. S. (2023). Cerebellopontine Angle Cancer. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK559116/

Mead, P. (2022). Epidemiology of Lyme Disease. Infectious Disease Clinics, 36(3), 495–521. https://doi.org/10.1016/j.idc.2022.03.004

Murphy, S. JX., & Werring, D. J. (2020). Stroke: Causes and clinical features. Medicine, 48(9), 561–566. https://doi.org/10.1016/j.mpmed.2020.06.002

Mustafa, A. H. K., & Suleiman, A. M. (2020). Bell’s Palsy: A Prospective Study. International Journal of Dentistry, 2020, e2160256. https://doi.org/10.1155/2020/2160256

Powers, W. J. (2020). Acute Ischemic Stroke. New England Journal of Medicine, 383(3), 252–260. https://doi.org/10.1056/NEJMcp1917030

Singh, A., & Deshmukh, P. (2022). Bell’s Palsy: A Review. Cureus. https://doi.org/10.7759/cureus.30186

Zhang, W., Xu, L., Luo, T., Wu, F., Zhao, B., & Li, X. (2020). The etiology of Bell’s palsy: A review. Journal of Neurology, 267(7), 1896–1905. https://doi.org/10.1007/s00415-019-09282-4

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