NUR5 6512 Case Study Assessing Neurological Symptoms
NUR5 6512 Case Study Assessing Neurological Symptoms
Patient Information:
S.
CC: “I have a headache around my forehead.”
HPI: J.K.L is a 40-year-old African American female who presents with a complaint of a headache across her forehead for a week. The headache is squeezing and feels like pressure behind the eyes. It is non-radiating. The headache is constant and varies in severity ranging from 2/10 at its best to 8/10 at its worst. It is usually worse in the morning and while bending. Acetaminophen reduces the severity of the headache to 4/10 and occasionally 2/10. It is associated with fever, postnasal drip, nasal congestion, sneezing, and occasional non-productive cough. She takes Sudafed HCL 120 mg every 12 hours to obtain some relief. The symptoms have significantly impaired her concentration at work and made her feel very tired. 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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ROS:
GENERAL: Reports fatigue and occasional fever. Denies weight loss, night sweats, and chills.
HEENT: Reports headaches, nasal congestion, post nasal drip, and sneezing. No blurring of vision, visual loss, hearing loss, tinnitus, nose bleeds, ear pain, mouth sores, or sore throat.
SKIN: no skin lesion or rashes. No abnormal pigmentation.
CARDIOVASCULAR: Negative for palpitations, chest pain, paroxysmal nocturnal dyspnea, and peripheral limb edema.
RESPIRATORY: Occasional non-productive cough. No difficulty in breathing, dyspnea, or orthopnea.
GASTROINTESTINAL: Reports loss of appetite and occasional nausea and vomiting. Denies change in bowel habits, abdominal pain, or distention.
GENITOURINARY: No frequency, dysuria, nocturia, and polyuria. No vaginal itchiness or abnormal vaginal discharge.
NEUROLOGICAL: Reports headache. Denies dizziness, lightheadedness, numbness, tingling, loss of sensation, syncope, and convulsion.
MUSCULOSKELETAL: No muscle pain, joint pains, muscle weakness, or muscle swelling.
HEMATOLOGIC: No anemia, easy bruising, or bleeding.
LYMPHATICS: Normal lymph nodes
PSYCHIATRIC: Denies anxiety, depression, suicidal ideations, or hallucinations.
ENDOCRINOLOGIC: Denies heat or cold intolerance, polyphagia, and polydipsia.
ALLERGIES: Reports no allergies.
O.
Physical exam:
VITAL SIGNS: BP 125/78 mmHg, HR 88 b/min, Temp 99. 8 F, RR 20 b/min, saturation 95% on room air, Height 168 cm, weight 76 Kg. Pain level 5/10
GENERAL: A middle-aged African-American female, well kempt, not in any form of respiratory distress but slight discomfort. Maintains eye contact, coherent speech, and a stable mood. Well-hydrated and nourished. No palmar or conjunctival pallor, jaundice, central or peripheral cyanosis, cervical or inguinal lymphadenopathy, and peripheral limb edema.
HEENT: Normocephalic and atraumatic head. Non-tender scalp. Bilateral eyes with pink conjunctiva and white sclera. Pupils equally
and bilaterally reacting to light, no ptosis or lid edema. Normal extraocular movements. Bilateral ears present, no impaction or skin lesions, tympanic membrane pearly grey bilaterally, and positive white reflex. Both nares are present and are discharging mucus, midline nasal septum, and pink and soft nasal mucosa. Tender maxillary and frontal sinus. Moist and pink oral mucosa, no oral lesions or ulceration. Normal dentition and teeth alignment.
NECK: Soft neck. The trachea is central. Full range of motion, non-tender, no cervical lymphadenopathy, and no thyroid enlargement.
CARDIOVASCULAR: Regular heart rate. Normoactive precordium. Point of maximal impulse in the 5th intercostal space in the midclavicular line. S1 and S2 head, no murmurs, thrills, gallops, rubs, or heaves.
RESPIRATORY: Symmetrical chest that moves with respiration. No scars or skin lesions. Equal chest expansion and equal tactile fremitus bilaterally. Equal air entry, vesicular breath sounds, no wheezes, and crackles, and equal vocal fremitus in all lung zones.
NEUROLOGICAL: GCS 15/15, oriented to time, place, and person, intact short-term and long-term memory, good concentration, and a clear coherent speech. Cranial nerves 1 to 12 intact. Normotonic across all joints, normal bulk, and power 5/5 across all muscle groups in upper and lower extremities, deep tendon reflexes 2+ and equal bilaterally in upper and lower limbs. Intact monofilament sensation across all dermatomes, good bowel, and bladder function. No spinal tenderness, normal gait, coordination, graphesthesia, and stereognosis. Normal finger nose, heel to the shin, and rapid alternating movements tests.
Diagnostic results:
J.K.L appears to have an inflammatory/infectious condition. Consequently, complete blood count and inflammatory markers particularly CRP and ESR are paramount. Similarly, bacterial or fungal cultures obtained endoscopically or by direct sinus aspiration are required to identify the possible pathogen. Additionally, a skin prick test is essential to exclude allergic rhinitis. Imaging modalities principally Sinus CT and MRI are recommended to evaluate for rhinosinusitis and intraorbital or intracranial involvement.
A.
Differential Diagnoses
Acute Sinusitis- refers to the inflammation of sinuses lasting less than 4 weeks (DeBoer & Kwon, 2022). The condition is more common in females and particularly during early fall to early spring (DeBoer & Kwon, 2022). It is most commonly caused by viral infection following a common cold although bacteria and fungi are not uncommon etiologies. J.K.L presents with clinical features that are typical of acute sinusitis including fatigue, fever, headache, facial pain, and pressure worse on bending (DeBoer & Kwon, 2022). Maxillary sinuses and frontal sinuses appear to be the affected sinuses in her as evidenced by pain around the forehead and tenderness of the maxillary and frontal sinuses (DeBoer & Kwon, 2022).
Rhinitis- Refers to the inflammation of the nasal mucosa. J.K.L presents with clinical manifestations suggestive of rhinitis including sneezing, nasal congestion, postnasal drip, and rhinorrhea (Liva et al., 2021). Similarly, she reports a “head cold” three weeks ago. Rhinitis is mostly caused by an upper respiratory infection or type 1 hypersensitivity reaction (Liva et al., 2021). However, an upper respiratory tract infection is likely the cause in her case.
Cluster headache- Cluster headache is a type of primary headache that is usually unilateral retro-orbital and characterized by sharp and stabbing pain (Goadsby et al., 2018). Cluster headache may present with symptoms of lacrimation, nasal congestion, rhinorrhea, ptosis, or miosis (Goadsby et al., 2018). However, it is unlikely the diagnosis in her as cluster headache usually lasts for a brief period. Similarly, cluster headaches mostly awake the patient at night.
Migraine headache- Migraine headache is another type of primary headache that may be preceded with or without aura. It is usually pulsating and moderate to severe (Pescador Ruschel & O, 2022). It is common in young women. However, it is unlikely the diagnosis as migraines last 4 to 72 hours if untreated and are typically associated with nausea, vomiting, photophobia, and phonophobia (Pescador Ruschel & O, 2022).
Rebound headache– Commonly referred to as medication overuse headache. Rebound headache predominantly occurs in individuals with primary headaches who overuse analgesia (Micieli & Robblee, 2018). Rebound headaches are more common in females and individuals less than 50 years. Drugs precipitating this headache include barbiturates, acetaminophen, opioids, ergotamine, and triptans (Micieli & Robblee, 2018). However, this is an unlikely diagnosis in J.K.L as a diagnosis of primary headache hasn’t been established.
NUR5 6512 Case Study Assessing Neurological Symptoms References
DeBoer, D. L., & Kwon, E. (2022). Acute Sinusitis. https://pubmed.ncbi.nlm.nih.gov/31613481/
Goadsby, P., Wei, D.-T., & Yuan Ong, J. (2018). Cluster headache: Epidemiology, pathophysiology, clinical features, and diagnosis. Annals of Indian Academy of Neurology, 21(5), 3. https://doi.org/10.4103/aian.aian_349_17
Liva, G. A., Karatzanis, A. D., & Prokopakis, E. P. (2021). Review of rhinitis: Classification, types, pathophysiology. Journal of Clinical Medicine, 10(14), 3183. https://doi.org/10.3390/jcm10143183
Micieli, A., & Robblee, J. (2018). Medication-overuse headache. Journal de l’Association Medicale Canadienne [Canadian Medical Association Journal], 190(10), E296–E296. https://doi.org/10.1503/cmaj.171101
Pescador Ruschel, M., & O, D. J. (2022). Migraine Headache. https://pubmed.ncbi.nlm.nih.gov/32809622/
HPI: K.L., a 40-year-old Caucasian woman, complains of a headache she’s had for a week. She mentions having a “head cold” three weeks ago. She adds that she thought things were improving, but her sinus issues have returned and are growing worse. She says the pain is across her forehead, feels like tension behind her eyes, and prevents her from breathing via her nose. The posterior part of her throat is also filled with mucous, she notices. She asserts that acetaminophen lessens the pain from being occasionally severe (8/10) to being moderate (4/10) and sporadically mild (2/10). Additionally, she mentions sporadic nonproductive coughing. She reports experiencing occasional fevers, frequent sneezing, and a lack of appetite. She claims that bending over seemed to aggravate her headache. Additionally, she takes 120 mg of Sudafed HCL every 12 hours, which offers some comfort. She asserts that she awakes with a headache and that her manifestations are worse in the morning. She claims that the pain is between 2/10 at its best and 8/10 at its worst. She also mentions having trouble focusing at work and feeling quite exhausted.
Location: Forehead
Onset: 3 weeks ago
Character: feels like tension behind her eyes, and prevents her from breathing via her nose
Associated signs and symptoms: sporadic nonproductive coughing, fevers, frequent sneezing, and a lack of appetite.
Timing: worse in the morning
Exacerbating/ relieving factors: acetaminophen lessens the pain from being occasionally severe (8/10) to being moderate (4/10) and sporadically mild (2/10). bending over seemed to aggravate her headache
Severity: pain is between 2/10 at its best and 8/10 at its worst
Current Medications:
- Acetaminophen 1300mg orally after every 8 hours PRN
- Sudafed HCL 120 mg every 12 hours
Allergies: none
PMHx:
- Confirms having had chickenpox as a kid in the past.
- Immunization status: All vaccines are current, with the most recent being a 3-year-old tetanus dose.
- Denies having any prior surgical procedures.
- Hospitalization: She strongly denies having ever been in a hospital.
Soc Hx: The patient is presently a student in an economics master’s degree. She works for a financial company and has done so for the previous six years. She’s been married to the same person for the last five years. She and their two boys reside in Florida with her boyfriend. The catholic she is. She works out frequently and makes an effort to eat a healthy diet. She admits to occasionally drinking wine, but only on special occasions. denies using cigarettes or any other addictive substance.
Fam Hx: At 81 years old, the father is still alive and treating coronary artery disease, HTN, and skin cancer. Mother passed away from breast cancer at the age of 71. All of the grandparents died without any known health issues. The patent only has one sibling, a 55-year-old who is dealing with CVA.
ROS:
GENERAL: There were no complaints of weariness, chills, sweating during the night, or weight changes.
HEENT: symptoms include a headache, eye pressure, difficulty breathing through the nose, throat mucous, intermittent but ineffective coughing, persistent sneezing, and lack of appetite.
SKIN: There are no rashes or sores, and the skin is warm and healthy.
CARDIOVASCULAR: The heart rate is normal. There were no further heartbeats or murmurs heard.
RESPIRATORY: The patient occasionally coughs ineffectively.
GASTROINTESTINAL: There were no reports of stomach aches, nausea, or vomiting.
GENITOURINARY: There were no complaints of urinary urgency, burning, or frequency.
NEUROLOGICAL: Reports symptoms include a headache and eye pressure. She says the pain is across her forehead and feels like tension behind her eyes.
MUSCULOSKELETAL: There were no reports of joint discomfort, muscular weakness, or muscle pain.
HEMATOLOGIC: There was no evidence of lymphadenopathy.
LYMPHATICS: There was no pronounced swelling of the lymph nodes.
PSYCHIATRIC: There were no reported mood swings, suicidal thoughts, or anxiety.
O.
Physical exam:
Vitals: BP 127/98; P 77; T 99.6; R 20 PsaO2 99% room air. Ht 5’7 Wt 159 BMI: 24.90
General: The patient exhibits signs of discomfort but seems well-nourished and developed.
Neurological: Awake and completely alert. The patient denies having numbness and tingling in both his lower and upper extremities. Reports throbbing unilateral headache in the frontal area ranging from 2 to 8/10. Denies aura and has difficulty walking. Both short-term and long-term memory are intact. Normal gait. Gross and fine motor abilities are both intact. Cranial nerves I-X are unaffected.
Diagnostic results: To help rule out an infection and assess for anemia, which can induce headaches, a complete blood count (CBC) may be prescribed. To check for structural irregularities or signs of trauma, a CT scan or other head imaging investigation may be required. MRI may be needed to rule out further headache reasons, such as brain tumors. (EEG) Electroencephalogram. To exclude any neurological or seizure conditions, an electroencephalogram (EEG) may be performed.
A.
Differential Diagnoses:
- Migraine Headache: The patient reported having migraines for a week, describing the pain as varying from 2 to 8 on a scale of 10, worst in the morning, and alleviated by acetaminophen (Gupta & Gaurkar, 2022).These symptoms fit the description of migraine headaches, a neurological condition that can produce frequent, severe headaches along with additional symptoms including nausea and sound and light sensitivity (Gupta & Gaurkar, 2022). The individual’s age and sex, together with the existence of several other symptoms, all support this diagnosis.
- Cluster headache: Severe, persistent headaches that come in clusters are the hallmark of cluster headaches. They generally are orbital (occurring around or behind the eyes) and unilateral (occurring on one side of the head) (Ray et al., 2022). Conjunctival injection, congestion in the nose, rhinorrhea, and facial sweat are among the symptoms that are often present. They can last for anywhere between 15 minutes and three hours (Ray et al., 2022). Given her advanced age and a history of cluster headaches, the woman in this case exhibits many of the classic symptoms of the condition. Additionally, the patient claims that using acetaminophen reduces their pain from 8/10 to 4/10, which is similar to other cluster headache therapies including triptans, oxygen, and steroids (Ray et al., 2022).
- Tension Headache: Patients who complain of headaches frequently have tension headaches investigated as a diagnosis. It is a common headache disease characterized by heightened head, neck, and scalp muscular tension. It frequently has a bilateral distribution and a dull, painful, or pressure-like feeling. It may cause a sense of stiffness in the neck and head muscles and range in severity from moderate to severe (Mansoureh Togha et al., 2022). Tension headache is a possible diagnosis based on the individual’s medical history and physical examination results. The patient’s account of the headache is in line with the tension headache criteria, and the observation that acetaminophen provides relief from the pain further supports this diagnosis.
- Acute Sinusitis: The patient has been complaining of loss of appetite for the last week as well as headaches, nasal congestion, mucus running down the throat, occasional nonproductive coughing, and constant sneezing. Acute sinusitis is diagnosed based on these symptoms and indications. According to Patel et al. (2018), a bacterial or viral infection is frequently the cause of a sinus infection. The individual’s observation that her complaints worsen in the morning when she wakes up with a headache while acetaminophen lessens but does not cure the headache supports a sinus infection even more.
- Allergic Rhinitis: The patient had a headache, tension behind her eyes, difficulty breathing through her nose, mucus in her throat, sporadic but continuous coughing, and a lot of sneezing. These signs and symptoms support the diagnosis of allergic rhinitis (Nur Husna et al., 2022). Allergic rhinitis, which can range in severity from moderate to severe, is an inflammation in the nasal passages brought on by allergens. A physical examination with findings of conjunctival erythema, erythematous and inflamed nasal mucosa, and clear mucopurulent discharge are consistent with allergic rhinitis even if the patient has not previously reported any allergies.
NUR5 6512 Case Study Assessing Neurological Symptoms References
Gupta, J., & Gaurkar, S. S. (2022). Migraine: An Underestimated Neurological Condition Affecting Billions. Cureus. https://doi.org/10.7759/cureus.28347
Mansoureh Togha, Jafari, E., Ansari, H., Haghighi, S., & Seyed Ehsan Mohammadianinejad. (2022). Headache and Migraine in Practice. Academic Press.
Nur Husna, S. M., Tan, H.-T. T., Md Shukri, N., Mohd Ashari, N. S., & Wong, K. K. (2022). Allergic Rhinitis: A Clinical and Pathophysiological Overview. Frontiers in Medicine, 9. https://doi.org/10.3389/fmed.2022.874114
Patel, Z. M., & Hwang, P. H. (2018). Acute Bacterial Rhinosinusitis. Infections of the Ears, Nose, Throat, and Sinuses, 133–143. https://doi.org/10.1007/978-3-319-74835-1_11
Ray, J. C., Stark, R. J., & Hutton, E. J. (2022). Cluster headache in adults. Australian Prescriber, 45(1), 15–20. https://doi.org/10.18773/austprescr.2022.004