NURS 6512 Assignment 1: Case Study Assignment: Assessing Neurological Symptoms

Patient particulars

Initials: G.G

Age: 48years

Sex: male

Race: American

Subjective Data

Chief complaint: I cannot feel my toes on the left foot. I have a tingling sensation in my right heel.

History of presenting illness: G.G is a 48years old male presenting with an inability to feel his toes on the left foot and a tingling sensation on the right foot. These symptoms are of gradual onset over four months. These symptoms proceed with pain in the feet that was sharp and aching. The pain increases in intensity on walking, touch, and cold season. The pain does not radiate, is worse at night, and resting relieves the pain. Other associating symptoms are the weakness of the limbs, burning sensation, muscle spasms of the lower limbs, and reports of loss of memory. The patient denies joint pain and stiffness.

Current medication:

metformin 850MG PO BD for diabetes mellitus,
Tylenol 1g PO PRN for pain and
HCTZ 50mg PO for hypertension

Allergies: the patient denies food and drug allergies

Past medical history: the patient has diabetes mellitus and hypertension. However, he does not go for regular

NURS 6512 Assignment 1 Case Study Assignment Assessing Neurological Symptoms

checks in the hospital. He is not compliant with his treatment. He denies hospital admission, blood transfusion, and surgical procedure.

Social history: the patient is married and has two children. He works as a call center manager. He enjoys reading novels. He takes alcohol every day and smokes tobacco. He takes fast food and does not engage in physical exercise. He does not use his phone while driving. He uses a safety belt while driving and has smoke detectors in his house.

Family history: he is the last born in a family of three. His father passed on at the age of 60years old due to a heart attack. His 70years old mother is obese and has coronary heart disease and osteoarthritis. His elder brother has hypertension and diabetes mellitus. His sister had her left limb amputated up to the ankle joint due to a diabetic foot. His grandparents passed on due to old age. He denies a family history of cancer and psychiatric diseases.

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Review Of Systems

General: the patient denies fatigue, malaise, fever, and weight loss.

HEENT: The patient denies headache, throat pain, nasal discharge, loss of hearing, visual loss, and blurring of vision.

Respiratory system: the patient denies coughing, running nose, wheezing, sputum production, chest pain, tachypnea, and shortness of breath.

Cardiovascular system: the patient denies chest pain, syncope, dyspnea, and orthopnea.

Gastrointestinal system: the patient denies abdominal pain, diarrhea, vomiting, heartburn, and reflux.

Genitourinary system: the patient denies dysuria, hematuria, urgency, and incontinence.

Neurological system: the patient presents with paralysis, ataxia, numbness, and tingling in the extremities. However, he denies change in bowel or bladder control.

Musculoskeletal system: the patient denies back pain, joint pain, or stiffness.

Hematologic system: the patient denies anemia, bleeding tendencies, or bruising.

Lymphatic system: the patient denies enlarged nodes and spleen enlargement.

Psychiatric: the patient denies depression, insomnia, anxiety, and hallucinations.

Endocrine system: the patient denies sweating, heat intolerance, polyuria, and polydipsia.

Allergies: the patient denies asthma, hives, eczema, and rhinitis.

Objective Data

Physical examination: the patient is alert and oriented. He has cold and clammy hands and feet. However, he has no pallor, jaundice, cyanosis, edema, or dehydration.

Vitals: blood pressure is at 178/89mmHg, PR 88beats per minute, RR 16 cycles per minute, height 161 cm, weight 110kg, BMI 42.44kg/m².

Neurological examination: the patient assumes an upright gait and posture. However, he has tremors in the fingers. He cannot perceive pinpricks and gross light touch. He has diminished tendon reflexes. However, the cranial nerves are intact.

Skin: the patient has dry and crusty skin. The skin folds have wrinkles and dark sports. There are erythematous and tender lesions around the joints.

Musculoskeletal system: the patient has muscle wasting on the upper and lower limbs. The bulk, tone, and power are reduced. However, there is no bone deformity or joint swelling.

Cardiovascular system: the heartbeat is at the 5^th ICS MCL with S1 and S2. There are no murmurs, rubs, or JVD. The peripheral pulse is present at a regular rate and rhythm. The capillary refill is less than 3sec in all four extremities.

Respiratory system: the chest wall is symmetrical with no scars or mass. The breathing is quiet and unlabored. There is a resonant percussion note over the chest. The breath sounds are clear to auscultation in the upper and lower lobes. There are no rhonchi, stridor, or crackles.

Gastrointestinal system: the abdomen is soft, round, and non-tender with normal-active bowel sounds in all the four quadrants. There are no abdominal bruits and tenderness to light and deep palpation. The liver span is 1cm below the costal margin. There is a tympanic percussion note throughout. The spleen and bilateral kidneys are not palpable.

Diagnostic Tests

Lipid profile to rule out hyperlipidemia
HbA1c and fasting blood sugar to check the blood glucose control
Liver function tests
Erythrocyte sedimentation rate to rule out autoimmune reactions
Thyroid function test to rule out hyperthyroidism
Nerve conduction study findings
MRI plexus to rule out tumors

Assessment

The patient presents with numbness and tingling of the lower limb. Other associating symptoms are pain, muscle spasms, weakness of the limbs, and burning sensation. He has hypertension and diabetes mellitus and does not comply with medication. He leads a sedentary lifestyle, takes alcohol, and smokes tobacco. On examination, he has reduced muscle tone, bulk, power, and reflexes. The skin is cold and clammy with wrinkles and dark spots. Therefore, my differential diagnoses are diabetic neuropathy, transient ischemic attack, and alcoholic neuropathy.

Differential Diagnoses

Diabetic neuropathy
Transient ischemic attack
Alcoholic neuropathy

Diabetic neuropathy is a complication of diabetes mellitus common in patients above 40years old. The complication is a result of poor drug compliance and inadequate treatment. The patient presents with numbness, tingling sensation, muscle cramping, dryness of the skin, loss of sensation of skin pricks, absent tendon reflex, and painful paresthesia (Zakin, et al, 2019). In diabetes mellitus, the patient has reduced absorption of the complex vitamins due to their autonomic effects on the gastrointestinal system. This contributes to the numbness of extremities. Additionally, poor glycemic control causes damage to the nerves hence the patient loses sensation and causes muscle weakness and spasms. This is the actual diagnosis because the patient has diabetes mellitus and does not comply with treatment.

The transient ischemic attack is a neurological dysfunction caused by the brain and the spinal cord without infarction. It causes changes in behavior, memory, gait, speech, and movement. The risk factors are previous surgery, seizure, illicit drugs, metabolic diseases, and cardiovascular diseases (Amarenco, P. 2020). The presenting signs and symptoms are a reduced level of consciousness, muscle weakness, numbness, tingling sensation, loss of memory, and staggering gait. This patient has diabetes mellitus and similar symptoms of a stroke. Finger glucose test for hypoglycemia, cardiac enzymes, and head CT scan will help rule out TIA.

The toxic effects of alcohol cause damage to the autonomic and peripheral nerves. The autonomic effects on the gastrointestinal system cause mal-absorption of the complex vitamins (Sadowski, A., & Houck, R. C. 2018). This leads to thiamine deficiency that eventually induces neuropathy. The presenting signs and symptoms are weakness and muscle wasting, gait dysfunction, tremors, hypothermia, orthostatic hypotension, and paresthesia. However, it is not the actual diagnosis because the patient has no hypothermia, orthostatic hypotension, gait dysfunction, and tremors.

References

Amarenco, P. (2020). Transient ischemic attack. New England Journal of Medicine, 382(20), 1933-1941. DOI: 10.1056/NEJMcp1908837

Sadowski, A., & Houck, R. C. (2018). Alcoholic neuropathy. PMID: 29763031

Zakin, E., Abrams, R., & Simpson, D. M. (2019, October). Diabetic neuropathy. In Seminars in neurology (Vol. 39, No. 05, pp. 560-569). Thieme Medical Publishers. DOI: 10.1055/s-0039-1688978

Patient Information:

A.Y, 20 year-old African American male

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.

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).

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).

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