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NURS 6512 Week 5 Assignment: Assessment of Cognition and the Neurological System

Age: 40 years

Sex: Female

Race: African American

Source: Patient

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

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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.

ROS:

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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.

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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.

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CARDIOVASCULAR: Regular heart rate. Normoactive precordium. Point of maximal impulse
in the 5 th 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.

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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.

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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.

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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/

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