A 40 year old female presents with complaint of a headache for one week. Reports a “head cold” 3 weeks ago. Thought it was getting better, but sinus symptoms are back and even worse.
Describes the headache is located across her forehead; feels like pressure behind my eyes and unable to breathe out of nose. Also feels mucus running down the back of throat. Pain sometimes severe (8/10) but with acetaminophen reduces to moderate (4/10) and occasionally mild (2/10). Occasional nonproductive cough. Feels feverish at times; noted frequent sneezing and no appetite. Bending over seems to make the headache worse. “Acetaminophen improves my headache, but doesn’t take it away.” Taking Sudafed HCL 120 mg every 12 hours, with some relief. Symptoms are worse in the morning – awakes with a headache. Ranges from 2/10 at its best to 8/10. Difficulty with concentrating at job and feels very tired.
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Case Study Assignment: Assessing Neurological Symptoms
First Name Last Name
Institution
Professor
Submission Date
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Patient Information:
Initials: H.K.
Sex: Female
Age: 40 years
Race: European American
S.
Cc: “I have been having a headache.”
HPI: H.K., a 40-year-old European American woman, arrived at the clinic complaining of a
headache she had been suffering from for a week. She reported that the headache was located
across the forehead, and she described the headache as a feeling of pressure behind her eyes. She
reported that the headache is aggravated by bending forward and is relieved by acetaminophen.
She reported that the severity of the headache was 8/10 when it was worse, 4/10 after taking
acetaminophen, but currently, she rated it at 2/10. She reported that she had a “head cold” 3
weeks ago and thought it was getting better but currently the sinus symptoms have reoccurred
and they are even worse. She reported that she is unable to breathe through the nose due to the
pressure she feels behind the eyes, and she also has a history of postnasal drip. She reported that
Sudafed HCL which offers some relief but reported that the symptoms are worse in the morning.
She reported that she awakes in the morning with a headache, feels feverish at times, and she had
a loss of appetite and frequent sneezing. She added that she has concentration difficulty
especially when she is at work and she also feels very tired.
Medications:
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Oral Acetaminophen 500 mg as required
Oral Sudafed HCL 120 mg every 12 hours
Allergies: She has no known allergies
PMHx: The patient did not provide any major medical history, she has a history of ORIF for a
clavicle fracture, and she reported that her immunization history is up to date.
Soc & Substance Hx: She is a police officer who works with the Maryland police
department, her hobbies are baking and knitting. She is married and lives with her husband and
two children, she reported that she never operates her phone while driving and ensures she has
fastened the seatbelt. She reported that she takes a glass of wine daily and smokes shisha
occasionally when out with friends but denied using any recreational drugs.
Family Hx: She reported that her mother is deceased and she had congestive heart failure and
hypertension, the father is alive but he has asthma, diabetes, and testicular cancer. She reported
that her maternal grandparents died long ago in an accident while her paternal grandfather died
as a result of cardiac arrest and paternal grandmother is still alive but she has asthma, diabetes,
and hypertension.
ROS
GENERAL: She has a history of fatigue, fever, and appetite loss, but she denies experiencing
chills or having a sensitivity to cold or heat.
HEENT: Head: She has a history of headaches but denies experiencing lightheadedness or head
trauma. Eyes: She denies excessive tearing, sclera yellowness, visual disturbances, or eye
discharges. Ear: She disputes any ear discharge, ear pain, ringing in the ears, or hearing loss.
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Nose: She has a history of postnasal drip, sneezing, and nasal congestion but denies having
anosmia or epistaxis. Throat: She denies having a raspy voice, swallowing problems, or any
dental problems.
SKIN: She denies rashes, itchiness, or color changes.
CARDIOVASCULAR: She denies shortness of breath, palpitation, chest pain, or edema.
RESPIRATORY: She has a history of a nonproductive cough, chest pain, difficulty in breathing,
or fast breathing.
GASTROINTESTINAL: She admits to having lost her appetite in the past but claims not to have
experienced nausea, vomiting, or diarrhea.
NEUROLOGICAL: She admits to having experienced headaches in the past, but she claims not
to have experienced numbness, memory loss, seizures, tingling, or syncope.
MUSCULOSKELETAL: She denies back pains, joint stiffness, muscle weakness, or joint pain.
HEMATOLOGIC: She denies blood transfusion, easy bleeding, or bruising.
LYMPHATICS: She denies appendicectomy or enlarged nodes.
O.
VS: BP: 134/87, PR: 91, RR: 19, Temp- 97.3, O2 sat.- 98% on room air, Wt.– 146 lbs., Ht.- 5’8”,
BMI- 22.2 (Healthy).
GENERAL: She is a middle-aged woman who has decent nutrition, is neatly dressed, isn’t
visibly upset, is cooperative, and is aware of people, time, and location.
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SKIN: Her skin is as per her ethnicity without any rashes, it is intact, while on palpation it is
warm and well perfused, and there is a normal skin turgor.
HEENT: Head: Untraumatized, evenly distributed hair, no scars or swelling, and no discomfort
or lumps upon touch. Eyes: Conjunctiva and sclera that are clear, no eye discharge, regular
extraocular motions, PERRLA, and normal visual acuity. Ears: Tympanic membranes are
transparent, gray, and not enlarged, a normal external ear, and the whisper test was successful.
Nose: Normal shape, septum not deviated, patent nares but she has nasal flaring, nasal mucosa is
erythematous and edematous and there is nasal discharge, while on palpation there was
tenderness on palpation of the frontal and ethmoidal sinuses. Throat: Moist and intact mucous
membranes, tonsils not enlarged, and normal dentation.
CARDIO: Upon inspection, there are no jugular vein engorgement, chest abnormalities, or lower
limb edema. There is no tenderness when the chest is palpated, and the peripheral pulses are all
palpable and have a typical rate and rhythm. Auscultation revealed S1 and S2 with no murmurs.
RESP: The chest, which moves in reaction to breathing, does not appear to have any scars,
abnormalities, or use of accessory muscles. The lungs were resonant and the chest expanded
evenly on both sides on palpation. On auscultation, the breath sounds are heard and distinct on
both sides.
GASTRO: Her abdomen moves in time with her breathing, and she appears to be free of scars
and peristalsis. While the abdomen becomes tympanic upon percussion, all quadrants have
characteristic bowel sounds. None of the quadrants show any soreness or organomegaly when
palpated deeply or superficially.
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NEURO: Her cranial nerves and senses are uninjured, she is attentive and focused, stands up
straight, cooperates, and all of her muscular groups are in a normal tone and power. She speaks
regularly with the appropriate volume and tone, has good short- and long-term memory, normal
reflexes, and senses.
MUSC: An examination revealed no visible defects, a regular walk, no missing digits or limbs,
and no inflamed joints. Every joint in her body has a normal range of motion, and palpating her
joints revealed no stiffness or soreness.
Diagnostic studies:
Allergy skin test
Total serum IgE
A.
Allergic rhinitis: According to Bousquet et al. (2020), allergic rhinitis is an atopic condition that
is characterized by symptoms of postnasal drip, nasal pruritis, nasal congestion, and clear
rhinorrhea. Seasonal or intermittent allergic rhinitis is marked by a running nose, sneezing, and
watery eyes, while the clinical signs of chronic allergic rhinitis include postnasal drip, ongoing
congestion, and obstruction. The clinical signs of the condition as similar, but the nasal discharge
is clear, and the patient also experiences irritation in the eyes and nose, which and both brought
on by an infection.
Acute sinusitis: An infection of the sinuses is usually present together with acute sinusitis, which
causes temporary sinus swelling (Wyler & Mallon, 2019). Nasal congestion, headaches, mucus
leakage, pressure in the ears, and fever are symptoms of acute sinusitis that are caused by a viral
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infection in the sinuses. The clinical signs are similar; however, this condition also includes a
pressure ache in the forehead that spreads to the neck.
Fungal sinusitis: According to Akhondi et al. (2022), the phrase “fungal sinusitis” is a broad term
used to describe several circumstances in which fungus may be the root of or contribute to nasal
and sinus inflammation. It is characterized by a terrible smell coming from the nose or a
diminished sense of smell, fever, sinus and nasal edema, nasal congestion, runny nose,
discomfort, tenderness, and pressure in the sinus region. Touching your cheeks or forehead could
hurt, and sinus headaches are also possible.
Infectious rhinitis: Liva et al. (2021) highlighted that viral rhinitis, also known as infectious
rhinitis, is a disorder in which a virus infects the nose and throat, causing the lining to become
inflamed. Postnasal drip, facial or dental pain, coughing, nasal congestion, and purulent
rhinorrhea, and these symptoms are its hallmarks.
Chronic rhinitis: Chronic rhinitis is characterized by recurring nasal obstruction or discharge that
doesn’t go away on its own, and its symptoms are brought on by ongoing irritation or
inflammation of the nasal interior (Sedaghat et al., 2022). Common symptoms of chronic rhinitis
include runny nose, postnasal drip, mouth breathing, nasal congestion, sinus pressure, sinus
infections, throat soreness, and a persistent cough.
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References
Akhondi, H., Woldemariam, B., & Rajasurya, V. (2022). Fungal sinusitis. In StatPearls
[Internet]. StatPearls Publishing.
Bousquet, J., Anto, J. M., Bachert, C., Baiardini, I., Bosnic-Anticevich, S., Walter Canonica, G.,
… & Toppila-Salmi, S. (2020). Allergic rhinitis. Nature Reviews Disease Primers, 6(1),
95.
Liva, G. A., Karatzanis, A. D., & Prokopakis, E. P. (2021). Review of rhinitis: classification,
types, pathophysiology. Journal of clinical medicine, 10(14), 3183.
Sedaghat, A. R., Kuan, E. C., & Scadding, G. K. (2022). Epidemiology of chronic rhinosinusitis:
prevalence and risk factors. The Journal of Allergy and Clinical Immunology: In
Practice, 10(6), 1395-1403.
Wyler, B., & Mallon, W. K. (2019). Sinusitis update. Emergency Medicine Clinics, 37(1), 41-54.
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Episodic/Focused SOAP Note Template
Assessing Neurological Symptoms
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete 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, runny nose or 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.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, 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: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
O.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
A .
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
P.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
© 2021 Walden University, LLC Page 1 of 3
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ASSESSING NEUROLOGICAL SYMPTOMS
Case: A 40 year old female presents with complaint of a headache for one week. Reports a “head cold” 3 weeks ago. Thought it was getting better, but sinus symptoms are back and even worse.
Describes the headache is located across her forehead; feels like pressure behind my eyes and unable to breathe out of nose. Also feels mucus running down the back of throat. Pain sometimes severe (8/10) but with acetaminophen reduces to moderate (4/10) and occasionally mild (2/10). Occasional nonproductive cough. Feels feverish at times; noted frequent sneezing and no appetite. Bending over seems to make the headache worse. “Acetaminophen improves my headache, but doesn’t take it away.” Taking Sudafed HCL 120 mg every 12 hours, with some relief. Symptoms are worse in the morning – awakes with a headache. Ranges from 2/10 at its best to 8/10. Difficulty with concentrating at job and feels very tired.
· 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.
Rubric for grading
This criterion is linked to a Learning OutcomeUsing 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.= 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.
This criterion is linked to a Learning Outcome· List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.= 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.
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.= 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.
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation.
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.
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