CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS ESSAY

CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS ESSAY

CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS ESSAY

Week 9 Shadow Health Comprehensive SOAP Note Template

SUBJECTIVE DATA:

Chief Complaint (CC): “Slanted mouth.”

History of Present Illness (HPI): K.M. is a 22-year-old African-American female who presents with a chief complaint of a slanted mouth. She states that she looked at herself in the mirror in the morning and noticed the left side of her mouth is slanted when she smiles. She reports she has had some headaches off and on that started a few days ago. She also noted that her taste had diminished when she started brushing her teeth.

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Medications:  No current meds.

Allergies: Allergic to nuts- cause a rash.

Past Medical History (PMH): No history of chronic diseases.

Past Surgical History (PSH): Tonsillectomy at 8 years.

Sexual/Reproductive History: LMP- 9 days ago. No history of STIs. Para 0+0. Reports normal menses. She is sexually active and uses condoms for protection.

Personal/Social History: K.M. is an accounting intern at an auditing firm. She is single and recently moved out of her parent’s house. She drinks whiskey on weekends 3-4 glasses and uses recreational marijuana. She denies smoking.

Health Maintenance: Attends annual well-exams. Goes to the gym 4-5 days a week. Sleeps 7-8 hours a day. Eats at least 3 meals a day.

Immunization History: Last TT-5 years ago; Last Flu shot-4 months ago.

Significant Family History: The paternal grandmother has HTN and a history of a heart attack. Maternal grandmother has Arthritis. The parents and siblings are alive and well.

Review of Systems:

General: Denies fatigue, fevers, chills, or weight changes.

HEENT: Denies head injury, blurred vision, eye pain, ear pain, hearing loss, rhinorrhea, or throat pain.

            Respiratory: Denies cough, wheezing, or sputum.

Cardiovascular/Peripheral Vascular: Denies edema, SOB, or palpitations.

            Gastrointestinal: Denies nausea, vomiting, or abdominal pain.

            Genitourinary: Denies dysuria or vaginal symptoms.

            Musculoskeletal: Denies joint pain, back pain, or muscle pain.

Neurological: Reports left-sided face drooping, headaches, and diminished sense of taste.

            Psychiatric: Denies anxiety or depressive symptoms.

Skin/hair/nails: Denies skin rash, bruises, brittle nails, or thinning hair.

OBJECTIVE DATA:

Physical Exam:

Vital signs: BP-116/74; HR-78; RR-16; Temp-98.4

General: The patient is alert, oriented, cooperative, and has clear speech.

HEENT: Head: Atraumatic; Facial asymmetry, Mask-like, and sagging face. The patient cannot wrinkle the forehead, grimace, or smile on the left side. Eye: PERRLA, White sclera, Pink conjunctiva. Ears: TMs are clear. Nose: Clear nostrils. Throats: Tonsillar glands are non-inflamed.

Neck: Full ROM; Symmetrical.

Chest/Lungs: Uniform chest expansion; Smooth respirations; Lungs clear bilaterally.

Heart/Peripheral Vascular: Regular heart rate and rhythm. S1 and S2 are present.

Abdomen: Soft; BS present in all quadrants; No tenderness, or organomegaly.

Genital/Rectal: Normal female genitalia; Anal sphincter intact.

Musculoskeletal: Well-aligned spine; Full ROM of joints.

Neurological: Unilateral paralysis of facial muscles. Diminished taste sensation.

Skin: Brown, warm skin. No discoloration or lesions.

Diagnostic results: Head CT scan: Normal

ASSESSMENT:

Bell Palsy (G51. 0): Bell Palsy is characterized by an abrupt onset of unilateral facial weakness. Symptoms include a drawing sensation, drooling, and impaired taste gets impaired to some level (Zhang et al., 2020). Bell palsy is the primary diagnosis based on the patient’s findings of left-sided facial weakness resulting in a mask-like and sagging face and inability to wrinkle the forehead, grimace, or smile on the left side. A diminished sense of taste is also a positive symptom.

Sarcoidosis (D86. 0): Sarcoidosis is characterized by neurologic involvement, which can affect any cranial nerve. Involvement of cranial nerve VII causes unilateral or bilateral facial palsy (Ungprasert et al., 2019). The patient has left-sided facial paralysis making Sarcoidosis a differential diagnosis.

Guillain-Barré syndrome (G61. 0): GBS is a leading cause of acute flaccid paralysis. It causes bilateral per or lower limbs bilaterally (Leonhard et al., 2019). This is a differential diagnosis based on the patient’s facial paralysis. However, the patient’s unilateral paralysis rules out GBS as the primary diagnosis.

Cerebral infarction (I63. 9): The Clinical symptoms of cerebral infarction include an abrupt onset of unilateral paralysis, impaired speech and language, double vision, impaired right/left discrimination, facial droop, and an altered level of consciousness (Kuriakose & Xiao, 2020). The patient’s unilateral facial paralysis and left-sided facial drooping make this a differential diagnosis.

Lyme Disease (A69. 20): Lyme disease causes peripheral nerve palsies that often contribute to facial paralysis. It is associated with tick bites (Radolf et al., 2021). Lyme disease is a differential owing to the patient’s facial paralysis. Nevertheless, the patient has no history of tick bites, ruling out Lyme disease as the primary diagnosis.

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

References

Kuriakose, D., & Xiao, Z. (2020). Pathophysiology and Treatment of Stroke: Present Status and Future Perspectives. International journal of molecular sciences, 21(20), 7609. https://doi.org/10.3390/ijms21207609

Leonhard, S. E., Mandarakas, M. R., Gondim, F., Bateman, K., Ferreira, M., Cornblath, D. R., van Doorn, P. A., Dourado, M. E., Hughes, R., Islam, B., Kusunoki, S., Pardo, C. A., Reisin, R., Sejvar, J. J., Shahrizaila, N., Soares, C., Umapathi, T., Wang, Y., Yiu, E. M., Willison, H. J., … Jacobs, B. C. (2019). Diagnosis and management of Guillain-Barré syndrome in ten steps. Nature reviews. Neurology, 15(11), 671–683. https://doi.org/10.1038/s41582-019-0250-9

Radolf, J. D., Strle, K., Lemieux, J. E., & Strle, F. (2021). Lyme Disease in Humans. Current issues in molecular biology, 42, 333–384. https://doi.org/10.21775/cimb.042.333

Ungprasert, P., Ryu, J. H., & Matteson, E. L. (2019). Clinical Manifestations, Diagnosis, and Treatment of Sarcoidosis. Mayo Clinic proceedings. Innovations, quality & outcomes, 3(3), 358–375. https://doi.org/10.1016/j.mayocpiqo.2019.04.006

Zhang, W., Xu, L., Luo, T., Wu, F., Zhao, B., & Li, X. (2020). The etiology of Bell’s palsy: a review. Journal of Neurology, 267(7), 1896–1905. https://doi.org/10.1007/s00415-019-09282-4

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22 year old african american female looks in the mirror and notices the left side of her mouth is slanted when she smiles. She notes she has had some headache off and on a few days. Her taste has decreased as well when she started brushing her teeth.

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. Template and course resources included.