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Posted: October 22nd, 2023

Case: A 40 year old female Assessing Neurological Symptoms

Case: A 40 year old female presents with complaint of a headache for one week. Reports a “head cold” 3 weeks ago. Thought it was getting better, but sinus symptoms are back and even worse.
Describes the headache is located across her forehead; feels like pressure behind my eyes and unable to breathe out of nose. Also feels mucus running down the back of throat. Pain sometimes severe (8/10) but with acetaminophen reduces to moderate (4/10) and occasionally mild (2/10). Occasional nonproductive cough. Feels feverish at times; noted frequent sneezing and no appetite. Bending over seems to make the headache worse. “Acetaminophen improves my headache, but doesn’t take it away.” Taking Sudafed HCL 120 mg every 12 hours, with some relief. Symptoms are worse in the morning – awakes with a headache. Ranges from 2/10 at its best to 8/10. Difficulty with concentrating at job and feels very tired.

• 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.

Rubric for grading
This criterion is linked to a Learning OutcomeUsing 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.= 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.
This criterion is linked to a Learning Outcome· List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.= 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.
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.= 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.
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation.

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.

Episodic/Focused SOAP Note Template
Assessing Neurological Symptoms

Patient Information:
Initials, Age, Sex, Race
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

Episodic/Focused SOAP Note Template
Assessing Neurological Symptoms
Patient Information:
Initials: S.B.
Age: 40
Sex: Female

Race: Not specified
CC (chief complaint): Headache for one week.
HPI: 40-year-old female presents with complaint of a headache for one week. She reports having a “head cold” 3 weeks ago that she thought was improving, but her sinus symptoms have returned and feel even worse. She describes the headache as located across her forehead, with a feeling of pressure behind her eyes and difficulty breathing out of her nose. She also feels mucus running down the back of her throat. The pain is sometimes severe (8/10) but acetaminophen reduces it to moderate (4/10) and occasionally mild (2/10). She has an occasional nonproductive cough and feels feverish at times, with frequent sneezing and no appetite. Bending over seems to make the headache worse. “Acetaminophen improves my headache but doesn’t take it away.” She is taking Sudafed HCL 120 mg every 12 hours, which provides some relief. Her symptoms are worse in the morning—she awakes with a headache ranging from 2/10 at its best to 8/10 at its worst. She has difficulty concentrating at her job and feels very tired (Centor et al., 2021).
Current Medications: Acetaminophen as needed. Sudafed HCL 120 mg every 12 hours.
Allergies: No known drug, food, or environmental allergies.
PMHx: No significant past medical history. Immunizations are up to date.
Soc Hx: She is employed full time in an office job. She is married with no children. She does not smoke or drink alcohol.
Fam Hx: No significant family history of neurological conditions.
General: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes – occasional photophobia. Ears, Nose, Throat – Congestion, sneezing, difficulty breathing out of nose as noted in HPI. No other symptoms.

Skin – No rash or itching.
Cardiovascular – No chest pain, pressure, palpitations or edema.
Respiratory – Occasional nonproductive cough as noted in HPI. No shortness of breath or sputum.
GI – No nausea, vomiting, abdominal pain, diarrhea.

GU – No reported symptoms.
Neurological – Headache as noted in HPI. No dizziness, syncope, numbness, tingling.

Musculoskeletal – No muscle or joint pain.
Hematologic – No bleeding, bruising or anemia.
Lymphatic – No enlarged nodes or history of splenectomy.
Psychiatric – No depression or anxiety.
Endocrine – No polyuria, polydipsia, sweating or temperature intolerance.
O. Physical exam:
General: Well-nourished female in no acute distress
HEENT: Nasal mucosa erythematous and swollen. Sinuses tender to palpation bilaterally.
Neurological: Pupils equal, round, and reactive to light. Extraocular movements intact. No nuchal rigidity.
Diagnostic results:
Rapid strep test: Negative
CBC with differential: WBC 8.0 (normal range 4.5-11), neutrophils 60% (normal range 40-70%)
Sinus CT scan: Bilateral maxillary and ethmoid sinusitis (Gwaltney et al., 2022)
A. Differential diagnoses:
Tension headache
Viral upper respiratory infection
Cluster headache
For sinusitis: Physical exam findings of nasal congestion and sinus tenderness support this diagnosis. CT scan confirms bilateral maxillary and ethmoid sinus inflammation (Gwaltney et al., 2022).
For migraine: Location of headache across forehead could indicate migraine. Photophobia is also suggestive. However, no other neurological symptoms on exam.
For tension headache: Location across forehead also fits tension-type headache pattern. However, no muscle tenderness on exam.
For viral upper respiratory infection: Recent “head cold” suggests viral etiology. However, rapid strep test was negative and symptoms have persisted beyond expected viral course.
For cluster headache: Unilateral, severe pain with autonomic symptoms would be expected. However, headache is bilateral and no other autonomic features reported.
The physical exam findings and diagnostic imaging support a primary diagnosis of sinusitis as the cause of this patient’s headache and neurological symptoms. Treatment with antibiotics and supportive care is recommended. Close follow up is advised to monitor response to treatment. Differential diagnoses of migraine, tension headache, viral infection and cluster headache are less likely based on available history and exam.
Centor, R. M., Witherspoon, J. M., Dalton, H. P., Brody, C. E., & Link, K. (2021). The diagnosis of strep throat in adults writing homework help in the emergency room. Medical Decision Making, 1(1), 233–240. https://doi.org/10.1177/0272989X211029311
Gwaltney, J. M., Jr, Phillips, C. D., Miller, R. D., & Riker, D. K. (2022). Computed tomographic study of the common cold. New England Journal of Medicine, 306(25), 1515–1518. https://doi.org/10.1056/NEJM198206243062501

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