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NURS 6512 Assignment Neurological Symptoms

NURS 6512 Assignment Neurological Symptoms

NURS 6512 Assignment Neurological Symptoms

HPI: J.K.L is a 40-year-old African American female who has been complaining of a headache across her forehead for a week. The headache is squeezing and feels like pressure behind the eyes. It does not emit radiation. The headache is constant and varies in severity from 2/10 to 8/10. It is usually worse in the morning and when bending. Acetaminophen reduces the severity of the headache to 4/10 and, on rare occasions, 2/10. It is characterized by fever, postnasal drip, nasal congestion, sneezing, and the occasional nonproductive cough. She takes Sudafed HCL 120 mg every 12 hours to get some relief. Her concentration at work has been significantly impaired, and she is extremely tired as a result of the symptoms. Finally, she reports a head cold three weeks ago.

Current Medications: Pseudoephedrine 120 mg BID for nasal congestion and acetaminophen for headaches.

Allergies: She has no known food and drug allergies.

Past Medical History: During her last visit to the primary care physician 2 months ago, she was noted to be prehypertensive and was advised on lifestyle modifications. No prior hospitalization. No previous surgeries or blood transfusions.

Social History: She is married with two children both alive and well. She works as a secretary Her husband is a college teacher. She neither drinks alcohol nor smokes tobacco. She does not use marijuana or other illicit drugs. She strictly adheres to dietary advice from her nutritionist and she exercises regularly. Denies caffeine intake.

Family History: Father alive aged 60 years and with hypertension while her mother is 58 years old alive and well. Her brother and sister are 35 and 20 years old respectively, alive and well. Her paternal grandfather died at the age of 80 years due to a heart attack while her paternal grandmother is 78 years and is hypertensive. Her maternal grandfather is 77 years with a history of type 2 diabetes and high cholesterol while her maternal grandmother died at the age of 70 years due to a stroke. No family history of malignancies, mental illness, asthma, sickle cell, or diabetes.

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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.

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.
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.

By Day 6 of Week 9

Submit your Assignment.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
• Please save your Assignment using the naming convention “WK9Assgn1+last name+first initial.(extension)” as the name.
• Click the Week 9 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
• Click the Week 9 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
• Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK9Assgn1+last name+first initial.(extension)” and click Open.
• If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
• Click on the Submit button to complete your submission.

Grading Criteria

To access your rubric:
Week 9 Assignment 1 Rubric

Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:
Submit your Week 9 Assignment 1 draft and review the originality report.

Submit Your Assignment by Day 6 of Week 9

To participate in this Assignment:

Week 9 Assignment 1

Week 9: Assessment of Cognition and the Neurologic System

A 63-year-old woman comes to your office because she’s been forgetting things…a young mother comes in concerned because her baby fails to make eye contact and is unresponsive to touch…a teenager comes in and a parent complains that the teen obsessively washes his hands.
An array of neurological conditions could be causing the above symptoms. When assessing the neurologic system, it is vital to formulate an accurate diagnosis as early as possible to prevent continued damage and deterioration of a patient’s quality of life.
This week, you will explore methods for assessing the cognition and the neurologic system.

Learning Objectives

Students will:

• Evaluate abnormal neurological symptoms
• Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for cognition and the neurologic system
• Assess health conditions based on a head-to-toe physical examination
________________________________________

Also Read:

NURS 6512 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment

NURS 6512 Assignment Assessing The Genitalia And Rectum

NURS 6512 Assignment Ethical Concerns

NURS 6512 Week 9 Assessment Of Cognition And The Neurologic System

NURS 6512 Assessment Tools and Diagnostic Tests in Adults and Children

NURS 6512 Assignment 1 Case Study Assignment Assessment Tools and Diagnostic Tests in Adults and Children

Discussion: NURS 6512 Assessing the Ears, Nose, and Throat

Discussion: NURS 6512 Assessment Tools and Diagnostic Tests in Adults and Children

Discussion: NURS 6512 Effective Communication

NURS 6512 Post an explanation of the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient you were assigned

Assignment: NURS 6512 Assessment Tools and Diagnostic Tests in Adults and Children

NURS 6512 The Ethics Behind Assessment

NURS 6512 Cognition and the Neurologic System

NURS 6512 Assessment of the Musculoskeletal System

NURS 6512 Assignment Cardiovascular Disease (CVD)

NURS 6512 Abdomen and Gastrointestinal System

NURS 6512 Functional, Cultural and Diversity Awareness in Health

NURS 6512 Building a Comprehensive Health History

NURS 6512 TJ Pregnant Lesbian Essay

NURS 6512 Health History of Tina Jones

NURS 6512 Discussion Week 1 Main Post

NURS 6512 Assignment 2 Focused Exam

NURS 6512 Practice Assessment Skin, Hair, and Nails Examination

NURS 6512 Digital Clinical Experience

NURS 6512 Tools and Diagnostic Tests in Adults and Children

NURS 6512 Episodic/Focused SOAP Note Template

NURS 6512 Discussion Episodic/Focused SOAP Note

NURS 6512 Discussion Adolescent Patients

NURS 6512 how social determinants of health such as age, gender, ethnicity, and environmental situation impact the health and risk assessment of the patients you serve

NURS 6512 The use of nursing theories is critical to patient care because of the different purposes that they serve

NURS 6512 Effective communication is required needed in any patient-healthcare provider interaction

NURS 6512 Primary care is a critical aspect of patient care

NURS 6512 Cultural beliefs played a key role in patient health

NURS 6512 Research the health-illness continuum and its relevance to patient care

NURS 6512 discuss the relevance of the continuum to patient care

NURS 6512 Cultural and linguistic competence

NURS 6512 it is important to treat all patients with respect and dignity despite any differences in race, ethnicity, socioeconomic status, sexual orientation, or belief systems

NURS 6512 Assessment tests and tools play an important role in the diagnosis of various diseases conditions in both adults and children

NURS 6512 Allergies

NURS 6512 Health assessment of the skin, hair and nails

NURS 6512 Asthma Diagnosis

NURS 6512 The abdomen and the gastrointestinal system Assignment

NURS 6512 Congestive Heart Failure

NURS 6512 Acute Lateral Ankle Sprain

NURS 6512 Lower Back Pain

NURS 6512 Bilateral Ankle Pain

NURS 6512 Discussion Categories to Differentiate Knee Pain

NURS 6512 Assessing The Neurologic System

NURS 6512 Hypertension

NURS 6512 Comprehensive Physical Assessment

NURS 6512 Assessment of the genitalia and rectum is vital in depicting genitourinary and gastrointestinal abnormalities respectively

NURS 6512 ethical dilemmas Assessment

NURS 6512 History of Present Illness (HPI)

NURS 6512 provision of quality and effective healthcare services to the diverse population

NURS 6512 Discussion comprehensive health history for a patient is important in developing a treatment plan for them

Learning Resources

Required Readings (click to expand/reduce)

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

• Chapter 7, “Mental Status”

This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms.

• ·Chapter 23, “Neurologic System”

The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 4, “Affective Changes”
This chapter outlines how to identify the potential cause of affective changes in a patient. The authors provide a suggested approach to the evaluation of this type of change, and they include specific tools that can be used as part of the diagnosis.

Chapter 9, “Confusion in Older Adults”
This chapter focuses on causes of confusion in older adults, with an emphasis on dementia. The authors include suggested questions for taking a focused history as well as what to look for in a physical examination.

Chapter 13, “Dizziness”
Dizziness can be a symptom of many underlying conditions. This chapter outlines the questions to ask a patient in taking a focused history and different tests to use in a physical examination.

Chapter 19, “Headache”
The focus of this chapter is the identification of the causes of headaches. The first step is to ensure that the headache is not a life-threatening condition. The authors give suggestions for taking a thorough history and performing a physical exam.

Chapter 31, “Sleep Problems”
In this chapter, the authors highlight the main causes of sleep problems. They also provide possible questions to use in taking the patient’s history, things to look for when performing a physical exam, and possible laboratory and diagnostic studies that might be useful in making the diagnosis.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
• Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5)
Note: Download the Physical Examination Objective Data Checklist to use as you complete the Comprehensive (Head-to-Toe) Physical Assessment assignment.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical examination objective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance Center.

Note: Download and review the Student Checklists and Key Points to use during your practice neurological examination.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Mental status: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Bearden , S. T., & Nay, L. B. (2011). Utility of EEG in differential diagnosis of adults with unexplained acute alteration of mental status. American Journal of Electroneurodiagnostic Technology, 51(2), 92–104.

This article reviews the use of electrocenographs (EEG) to assist in differential diagnoses. The authors provide differential diagnostic scenarios in which the EEG was useful.

Athilingam, P ., Visovsky, C., & Elliott, A. F. (2015). Cognitive screening in persons with chronic diseases in primary care: Challenges and recommendations for practice. American Journal of Alzheimer’s Disease & Other Dementias, 30(6), 547–558. doi:10.1177/1533317515577127

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NURS 6512 Assignment Neurological Symptoms
NURS 6512 Assignment Neurological Symptoms

Sinclair , A. J., Gadsby, R., Hillson, R., Forbes, A., & Bayer, A. J. (2013). Brief report: Use of the Mini-Cog as a screening tool for cognitive impairment in diabetes in primary care. Diabetes Research and Clinical Practice, 100(1), e23–e25. doi:10.1016/j.diabres.2013.01.001

Roalf, D. R., Moberg, P. J., Xei, S. X., Wolk, D. A., Moelter, S. T., & Arnold, S. E. (2013). Comparative accuracies of two common screening instruments for classification of Alzheimer’s disease, mild cognitive impairment, and healthy aging. Alzheimer’s & Dementia, 9(5), 529–537. doi:10.1016/j.jalz.2012.10.001. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036230/

Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us

Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)

Document: DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment (Word document)
Use this template to complete your Assignment 3 for this week.

Optional Resources

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

• Chapter 14, “The Neurologic Examination” (pp. 683–765)

This chapter provides an overview of the nervous system. The authors also explain the basics of neurological exams.

• Chapter 15, “Mental Status, Psychiatric, and Social Evaluations” (pp. 766–786)

In this chapter, the authors provide a list of common psychiatric syndromes. The authors also explain the mental, psychiatric, and social evaluation process.
Mahlknecht, P., Hotter, A., Hussl, A., Esterhammer, R., Schockey, M., & Seppi, K. (2010). Significance of MRI in diagnosis and differential diagnosis of Parkinson’s disease. Neurodegenerative Diseases, 7(5), 300–318.

Required Media (click to expand/reduce)

Neurologic System – Week 9 (16m)

Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 7 and 23 that relate to the assessment of cognition and the neurologic system. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/

Rubric Detail

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Content
Name: NURS_6512_Week_9_Assignment1_Rubric
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Using 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. Points Range: 45 (45%) – 50 (50%)
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. Points Range: 39 (39%) – 44 (44%)
The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. Points Range: 33 (33%) – 38 (38%)
The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected. Points Range: 0 (0%) – 32 (32%)

The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
· List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. Points Range: 30 (30%) – 35 (35%)
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. Points Range: 24 (24%) – 29 (29%)
The response lists four to five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected. Points Range: 18 (18%) – 23 (23%)
The response lists three to four possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or some inaccuracy in the conditions and/or justification for each.

Points Range: 0 (0%) – 17 (17%)
The response lists three or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition 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. Points Range: 5 (5%) – 5 (5%)
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. Points Range: 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. Points Range: 3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. Points Range: 0 (0%) – 2 (2%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation Points Range: 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors. Points Range: 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors. Points Range: 3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors. Points Range: 0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
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. Points Range: 5 (5%) – 5 (5%)
Uses correct APA format with no errors. Points Range: 4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors. Points Range: 3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors. Points Range: 0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors.

Patient Information:

A.Y, 20 year-old African American male

S.

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.

O.

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).

A.

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

Total Points: 100
Name: NURS_6512_Week_9_Assignment1_Rubric