Cheap essays, research papers, dissertations.NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Sample Answer for NURS 6512 Week 9: Assessment of Cognition and the Neurologic System Included After Question
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
Photo Credit: Kurt Drubbel/E+/Getty Images
NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 5, “Mental Status” (64-78)
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 22, “Neurologic System” (pp. 544-580)
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. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 4, “Affective Changes” (pp. 33-46)
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” (pp. 97-109)
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” (pp. 148-157)
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” (pp. 221-234)
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 28, “Sleep Problems” (pp. 345–355)
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”; p. 29)
Chapter 4, “Pediatric Preventative Care Visits” (” Neurological Reflexes That Should Be Tested During Infancy”; (p. 108)
Chapter 9, “Prescription Writing and Electronic Prescribing” (pp. 195-206)
Note: Download and review these Adult Examination Checklists and Physical Exam Summary to use during your practice neurological examination.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for mental assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Mental Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for neurologic assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Neurologic Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Neurologic system. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Neurologic System Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
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
Retrieved from the Walden Library Databases.
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
Retrieved from the Walden Library Databases.
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 http://www.alzheimersanddementia.com/article/S1552-5260(12)02463-6/abstract
University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved from http://www.med-ed.virginia.edu/courses/rad/index.html
This website provides an introduction to radiology and imaging. For this week, focus on head CTs in neuroradiology.
Required Media
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 5 and 22 that relate to the assessment of cognition and the neurologic system. Refer to the Week 4 Learning Resources area for access instructions.
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.
Discussion: Assessing Neurological Symptoms
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 Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the Episodic/Focused SOAP Note format, rather than the traditional narrative style Discussion posting 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.
Case 1: Headaches
A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.
Case 2: Numbness and Pain
A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools.
Case 3: Drooping of Face
A 33-year-old female comes to your clinic alarmed about sudden “drooping” on the right side of the face that began this morning. She complains of excessive tearing and drooling on her right side as well.
To prepare:
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.
Note: Before you submit your initial post, replace the subject line (“Discussion – Week 9”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.
By Day 3
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in 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.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Read a selection of your colleagues’ responses.
By Day 6
Respond to at least two of your colleagues on two different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.
Submission and Grading Information
Grading Criteria
To access your rubric:
Week 9 Discussion Rubric
Post by Day 3 and Respond by Day 6
To participate in this Discussion:
Week 9 Discussion
NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Assignment (Optional): Practice Assessment: Neurological Examination
Short of opening a patient’s cranium or requesting a brain scan, what can an advanced practice nurse do to determine the cause of neurological symptoms? A multitude of techniques can be used to generate a neurological diagnosis.
In preparation for the Head-to-Toe Physical Assessment Video due in Week 10, it is recommended that you practice performing a neurological examination this week.
Note: This is an optional practice physical assessment. You do not have to capture a video of this assessment, as no submission is required.
To prepare:
Arrange an appropriate time and setting with your volunteer “patient” to perform a neurological examination.
Download and review the Neurological Checklist provided in this week’s Learning Resources.
Ensure that you have a plexor (reflex hammer) to perform the examination.
To complete:
Perform the neurological examination. Be sure to cover all of the areas listed in the checklist and to use the plexor appropriately.
Looking Ahead: Head-to-Toe Physical Assessment Video
In Week 10, you will videotape yourself conducting a head-to-toe physical assessment.
By Day 7 of Week 10
This video is due. Refer to Week 10 for additional guidance.
Week in Review
This week, you properly applied the assessment techniques and diagnoses for cognition and the neurological system. In addition, you evaluated abnormal neurological symptoms and explained which physical exams and diagnostic tests would render the appropriate results needed to make a diagnosis.
Next week, you will explore how to assess problems with the breasts, genitalia, rectum, and prostate while making the patient feel safe, listened to and cared about using a non-invasive approach.
A Sample Answer For the Assignment: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Title: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Patient Information:
Initials: JS Age: 20 Sex: Male Race: Caucasian
CC (chief complaint): Headache
HPI: JS is a 20 year old Caucasian male who presents today with intermittent headaches. The headaches diffuse all over the head, but patient states the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbone, and jaw. He rates the pain as a 6/10 and states he has had headaches for around 2 weeks now. JS states he takes two Tylenol 325 mg when he has the headaches and this helps him somewhat. Patient states these headaches make it difficult for him to concentrate at work and at school.
Current Medications: Tylenol 325 mg- takes 2 about every 6 hours as needed.
Allergies: PCN
PMHx: Up to date on all shots, flu shot last year 10/18, childhood history of asthma and ear infections
Soc Hx: Works as a server at local restaurant while attending school at the university full time. Denies current or previous tobacco and alcohol use. Uses his cell phone frequently but does not use it while driving.
Fam Hx: Mother- HTN, Asthma, Father- denies medical history, does not know medical history of grandparents.
ROS:
GENERAL: Denies weight loss, fever, fatigue, sweats, or chills.
HEENT: Head: headaches for the last 2 weeks, Eyes: No visual loss or blurred vision. Ears, Nose, Throat: No drainage, hearing loss, or sore throat.
SKIN: Warm, dry, no rash or itching.
CARDIOVASCULAR: No chest pain or discomfort.
RESPIRATORY: No coughing or shortness of breath.
GASTROINTESTINAL: No nausea, vomiting, or diarrhea
GENITOURINARY: No burning or discomfort on urination.
NEUROLOGICAL: Headache for 2 weeks, no numbness or tingling.
MUSCULOSKELETAL: No muscle or back pain.
HEMATOLOGIC: No bleeding or bruising.
LYMPHATICS: No enlarged nodes.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Allergic to PCN, hx of asthma in childhood.
Physical exam: Vital signs- BP 120/70, HR-90, Temp- 98.2, RR-18, Wt-180, Ht-5’11.
General: JS is a 20 year old white male, A&O x4, in no apparent distress, calm and cooperative upon interview.
Head: Normal size and position, facial features symmetrical.
Eyes: Visual acuity 20/20 using Snellen chart, Eyes symmetrical, No nystagmus noted.
Neurological: Alert and oriented to person, place, time, and situation. Fluent in English language, thoughts and responses appropriate.
Diagnostic results:
CT scan- useful to detect intracranial disease
MRI- can detect any tumors or abnormalities
Lumbar puncture- Can be done in cases where CNS infection is suspected
A.
Differential Diagnoses:
Tension headache- Most common type of headache, cause mild to moderate pain and come and go over time.
Migraine headache- often described as pounding, throbbing pain. They can last from 4 hours to 3 days and usually happen one to four times a month. Along with the pain, people have other symptoms, such as sensitivity to light, noise, or smells, nausea or vomiting, loss of appetite, and upset stomach.
Cluster headache- These headaches are the most severe. You could have intense burning or piercing pain behind or around one eye. It can be throbbing or constant.
Sinus headache- With sinus headaches, you feel a deep and constant pain in your cheekbones, forehead, or on the bridge of your nose.
Posttraumatic headaches- Occur 2-3 days after a head injury, and include trouble concentrating, vertigo, and memory problems.
References
https://www.webmd.com/migraines-headaches/migraines-headaches-basics#2
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
A Sample Answer 2 For the Assignment: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Title: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Patient Information:
JT, 20 y/o, Male, Caucasian
Case 1: Headaches
A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.
CC: Pt c/o “headaches on and off throughout the day”
HPI: This is a 20 y/o Caucasian male who presents with a c/o severe h/a intermittently throughout the day. Pt states the pain begins at the crown of his head, continues above the eyes, travel to the nasal cavity, cheekbones and jaw area. Onset has been approximately one week with the pressure of the pain greatest above the eye. No n/v, no light sensitivity. Pt claims that pain is greatest when stressed at work in the day and will self medicate with Tylenol which makes the pain tolerable. Pt rates the pain as 8/10
Current Medications: Tylenol 650mg po q 6hr prn h/a.
Allergies: NKA
PMHx: Tdap 11/18/2019 negative for past surgical hx. Childhood asthma.
Soc Hx: Pt works as a computer technologist for a large company. Pt parents both smoke, pt smokes. Pt not interested in smoking cessation information at this time.
Fam Hx: Pt father has end stage COPD w/ chronic steroids usage and O2 dependant at 56y/o. Pt mother w/ hx of 2 pack per day cigarette habit, enphysema, migrains, CABG, NIDDM.
ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, no blurred vision. Ears, Nose, Throat: No hearing loss. No sneezing, positive for congestion, cough, sore throat and facial pressure noted.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, positive cough, no sputum production
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination.
NEUROLOGICAL: Localized headache w/ radiation to facial area. No dizziness syncope, paralysis, ataxia, numbness or tingling in the extremities.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: History of asthma, hives, eczema and rhinitis.
Vitals: B/P 143/71; Pulse 86; Temp 98.6; RR 20; O2 Sats 98% on RA; Wt 75kg
Physical exam:
General: Alert and oriented w/ some acute distress.
HEENT: Eyes: PEERLA. Ears, Nose, Throat: No hearing loss. No sneezing, positive for cough congestion core throat, post nasal drip. Facial pressure noted upon palpation (Inspecting the symmetry of the facial feature with various expressions is controlled by CN VII) (Ball, Dains, Flynn, Solomon, & Stewart, 2015).
NEUROLOGICAL: Localized headache w/ radiation to facial area. No dizziness syncope, paralysis, ataxia, numbness or tingling in the extremities.
MUSCULOSKELETAL: No muscle, back pain, neck pain, joint pain or stiffness.
Diagnostic results: CBC-rule out sinus infection (Dains, Baumann, & Scheibel, 2016). CMP- asses renal function and electrolytes (Dains, Baumann, & Scheibel, 2016).CT head- noninvasive diagnostic tool used to detect intracranial disease (Dains, Baumann, & Scheibel, 2016).
A.
Presumptive Diagnosis: Tension-Type Headache (TTH)
Differential Diagnoses
1. TTH: Can be bilateral, general or localized and characterized as frontotemporal distribution. Can be mild to moderate, throbbing tightness pressure lasting hours or days with frequent recurrences. Triggers can be related to stress, hunger or depression (Dains, Baumann, & Scheibel, 2016).
2. Migraine: Usually frontal or periorbital with rapid onset lasting for hours. Occurrences may be daily or weekly and common in adults 25-34 years of age. In fact, one study showed that asthma is associated with an increased risk for episodic migraine to chronic migraine (“Asthma Increases Risk for Migraine Chronification,” 2014). Mast cell degranulation or parasympathetic hyperactivity in asthma, can predispose a person to the future onset of chronic migraine (“Asthma Increases Risk for Migraine Chronification,” 2014). Another study states migraine patients have a higher risk of developing asthma.
3. Mixed Headache: A combination of vascular dysfunction and muscular contraction. Described as throbbing, tightness, pressure, and associated with familial history(Dains, Baumann, & Scheibel, 2016).
4. Sinusitis: Associated with facial pressure, sore throat, tooth pain, and sinus headache. Morning periorbital swelling, malaise, fever, and respiratory tract infection (Dains, Baumann, & Scheibel, 2016).
5. Dental Disorders: Severe headache and facial pain can be attributed to dental abscess, ulceration, infection, and sensitivity (Dains, Baumann, & Scheibel, 2016).
References
Asthma Increases Risk for Migraine Chronification. (2014, September). Retrieved from
https://www.mdedge.com/neurology/article/86796/headache-migraine/asthma-increases-
risk-migraine-chronification
Ball, J. W., Dains, J. E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2015). Seidel’s guide to
physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and
clinical diagnosis in primary care (5th ed.). St Louis, MO: Elsevier Mosby.
Hsieh, L. Y., Peng, Y. H., & Chia, H. L. (2016). MIGRAINE IS ASSOCIATED WITH AN INCREASED RISK OF ADULT-ONSET ASTHMA: A NATIONWIDE COHORT STUDY. Respiratory Care, 61(10).
A Sample Answer 3 For the Assignment: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Title: NURS 6512 Week 9: Assessment of Cognition and the Neurologic System
Patient Information:
R.H., 33, Female, Caucasian
CC: Sudden “drooping,” excessive tearing, and drooling on right side of face.
HPI: R.H. is a 33-year-old Caucasian female who presents to the clinic today with complaints of sudden “drooping” on the right side of her face. Associated signs and symptoms include excessive tearing and drooling on the right side of her face. Symptoms began suddenly this morning. She is experiencing no pain, 0/10, but is experiencing numbness on the right side of her face. She is alarmed and unsure what is going on. She has tried nothing to relieve her symptoms and has not noticed anything that makes it worse.
Current Medications:
1.) Ibuprofen 400mg PO q6 hrs PRN for pain
2.) Multivitamin PO once daily in am
Allergies:
NKA
PMH
1.) Generalized anxiety
2.) Headaches
PSH
1.) Appendectomy 1994
Sexual/Reproductive History:
Heterosexual
1-1-0-0-1
Social Hx:
Negative for current or past tobacco or illicit drug use. Drinks alcohol socially in moderation.
Immunization History: Up-to-date
Tetanus(Tdap): 2016
Influenza: 11/2018
Family Hx:
Mother, alive, age 62, hx overweight
Father, alive, age 59, hx chronic low back pain
Maternal Grandmother, deceased age 71, stroke, hx osteoporosis, dementia
Maternal Grandfather, deceased at age 69, MI, hx DM type 2
Paternal Grandmother, alive, age 101, hx cataracts, HTN, dementia, GI bleed
Paternal Grandfather, deceased at age 73, kidney failure, hx CKD
Brother, alive, 36, prehypertension
Lifestyle:
Patient is a self-employed event planner, married for 5 years with 1 dependent child age 1.5 years. Has support of husband, family, and friends. Diet is well-balanced, home cooked, consisting of three meals daily, and exercises 30-60 minutes 3-4 times a week. Has health insurance through her husband’s employer. Had annual examination with primary care provider approximately 6 months ago.
ROS:
General: No weakness or night sweats. No recent weight gain or loss of significance. Denies recent illness, fever, chills, or feeling fatigued.
HEENT: No history of head injury. No corrective lenses. Denies visual changes, diplopia, floaters, or photophobia. Reports recent excessive tearing. Denies any hearing difficulties or loss of hearing. Denies tinnitus, vertigo, infections, or nasal drainage. Denies any change in sense of smell. Denies any episodes of epistaxis, nasal polyps, or recent sinus infection. Denies bleeding gums; cavities that have been filled. Reports good oral care, last dental visit was 4 months ago. Reports recent drooping of right side of face with drooling on right side. Reports difficulty eating, drinking, and forming some words since facial drooping began.
Neck: Denies lumps, swollen glands, pain, or stiffness.
Breasts: Denies lumps, pain, changes in color or texture of skin, or nipple discharge.
Respiratory: Denies cough, shortness of breath, or night sweats.
Cardiovascular: Denies chest pain, pressure, palpitations, or orthopnea.
Gastrointestinal: Denies nausea, vomiting, diarrhea, or constipation. No melena or hematochezia. No pain, appetite is good. No known liver problems or gallbladder problems.
Genitourinary: No frequency, urgency, dysuria, hematuria, incontinence, flank pain, or dyspareunia. Annual physical examination completed 7/2018.
Peripheral vascular: Denies varicose veins, edema, phlebitis, leg pain, cyanosis, numbness or tingling in extremities.
Musculoskeletal: Denies any weakness, pain, joint swelling, or arthritis. Denies recent fall or trauma.
Integumentary: No rash or itching. Denies dermatitis or psoriasis.
Psychiatric: Reports generalized anxiety, no other history of psychiatric disorders. No thoughts of self-harm. Denies depression.
Neurologic: Denies headache, seizures, syncope, stumbling, changes in balance or coordination, or changes in memory. Reports drooping and numbness to right side of face. Reports difficulty eating, drinking, and speaking.
Hematologic: Denies anemia, bleeding, bruising, or history of clotting disorders. No history of blood transfusion.
Endocrine: No night sweats, cold or heat intolerance, polyuria. No excessive thirst or hunger.
Allergic/Immunologic: Denies asthma, eczema, or rhinitis. No known immune deficiencies.
Physical Examination
Vital signs:
BP: 126/72, right arm, sitting; HR: 76, regular; RR: 16, regular; T: 98.2 degrees F, tympanic; SpO2: 98% RA; W: 132 pounds, stable; Ht: 5’3”; BMI: 23.4
General Appearance: Alert and oriented x3, cooperative. Answers appropriately but with some speech difficulty. Patient appears to be worried and anxious but in no acute distress. Well-groomed, appropriately dressed.
HEENT: Hair of average texture. Scalp without lesions, normocephalic/atraumatic. Conjunctiva pink; sclera white. Pupils equal, round, regular, reactive to light. Extraocular movements intact. Right eyelid unable to close completely, sag to right lower lid, excessive tearing noted. Tympanic membranes visualized, clear canal and good cone of light, bilaterally. Acuity good to whispered voice. Mucosa pink, septum midline. Oral mucosa pink. Good dentition. Tongue midline, pink, and moist. Tonsils absent. Pharynx without exudates.
Neck: Trachea midline, supple, no palpable nodes
Lymph nodes: No lymphadenopathy in any nodes. No palpable cervical, axillary or epitrochlear nodes. Small inguinal nodes bilaterally, soft and nontender.
Chest: Heart rate regular with normal S1, S2; no S3, S4. No murmurs, rubs, and gallops.
Lungs: Lung expansion symmetrical, regular and non-labored, CTA without rales, wheezes or rhonchi.
Peripheral vascular: No pedal edema; 2+ dorsalis pedis pulses bilaterally, capillary refill less than 3 seconds.
Musculoskeletal: No obvious deformities, masses, discoloration, or enlarged joints. No musculoskeletal pain or limitation in ROM. Gait steady, able to move extremities appropriately.
Neurologic Mental Status: Awake, alert and oriented to person, place, and time. Cooperative. Deep tendon reflexes 2+lower extremity. Impaired speech. Facial sensation intact. Drooling noted to right side of mouth. Unable to wrinkle forehead, limited ability to close right eye or grimace.
Skin: Warm, moist, pale. Intact without lesions, rashes, or urticaria.
Diagnostics:
Diagnosis of Bell’s Palsy is typically based on clinical presentation (Hollier & Hensley, 2011).
CT – rule out stroke or neoplasm
Electromyographic (EMG) testing – determine severity and extend of nerve involvement
Lyme titer – if history of tick bite
(Hollier & Hensley, 2011).
MRI – if other neurological deficits are
