CASE STUDY 2: Drooping of Face
A 33-year-old feminine involves your clinic alarmed about sudden “drooping” on the correct aspect of the face that started this morning. She complains of extreme tearing and drooling on her proper aspect as nicely.
Project 1: Case Research Project: Assessing Neurological Signs
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Think about not with the ability to kind new recollections. That is the fact sufferers with anterograde amnesia face. Though this type of amnesia is uncommon, it might probably outcome from extreme mind trauma. Anterograde amnesia demonstrates simply how impactful mind issues may be to a affected person’s high quality of dwelling. Precisely assessing neurological signs is a posh course of that includes the evaluation of many components.
On this Case Research Project, you’ll contemplate case research that describe irregular findings in sufferers seen in a scientific setting.
To Put together
• By Day 1 of this week, you can be assigned to a particular case examine for this Case Research Project. Please see the “Course Bulletins” part of the classroom in your project out of your Teacher.
• Additionally, your Case Research Project needs to be within the Episodic/Targeted SOAP Notice format moderately than the normal narrative fashion format. Seek advice from Chapter 2 of the Sullivan textual content and the Episodic/Targeted SOAP Template within the Week 5 Studying Assets for steerage. Keep in mind that all Episodic/Targeted SOAP notes have particular knowledge included in each affected person case.
With regard to the case examine you have been assigned:
• Evaluate this week’s Studying Assets, and contemplate the insights they supply in regards to the case examine.
• Contemplate what historical past could be crucial to gather from the affected person within the case examine you have been assigned.
• Contemplate what bodily exams and diagnostic checks could be applicable to assemble extra details about the affected person’s situation. How would the outcomes be used to make a prognosis?
• Determine a minimum of 5 attainable circumstances that could be thought of in a differential prognosis for the affected person.
The Case Research Project
Use the Episodic/Targeted SOAP Template and create an episodic/centered word in regards to the affected person within the case examine to which you have been assigned utilizing the episodic/centered word template offered within the Week 5 sources. Present proof from the literature to help diagnostic checks that may be applicable for every case. Checklist 5 completely different attainable circumstances for the affected person’s differential prognosis, and justify why you.
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Pattern Reply
Episodic/Targeted SOAP Notice
Pupil’s Identify
Institutional Affiliation
Course
Professor’s Identify
Date
Episodic/Targeted SOAP Notice
Affected person Info:
JL, 33, Feminine, Black American
S.
CC (chief criticism): Drooping on the correct aspect of the face.
HPI: JL is a 33-year-old African American lady who presents to the clinic complaining of drooping on the correct aspect of the face. She states that the situation started this morning. She complains of extreme tearing and drooling on her proper aspect. She doesn’t complain of any ache.
Present Medicines:
Multivitamin each day
Valtrex 500mg PO * three each day.
Ibruprofen 200mg * 2 PO as wanted
Allergy symptoms:
No recognized drug allergy symptoms.
PMHx:
Bronchial asthma as an adolescent
Genital herpes in 2015
Soc Hx:
She drinks alcohol sometimes and doesn’t smoke. She give up taking marijuana 5 years in the past after being in a rehabilitation heart for six months. She denies taking laborious medication. She lives with the dad and mom and one youthful brother.
Fam Hx: She is single and lives with one brother who’s diabetic. The dad and mom are wholesome with no important well being historical past. Her grandparents died in a automotive accident at outdated age with none exceptional sickness. She has no grandchildren.
ROS:
GENERAL: The 33-year-old lady seems anxious about her well being situation. She has lived a wholesome life with out unintentional physique weight or loss or admission to a hospital.
HEENT: Eyes: No modifications in imaginative and prescient or listening to. Her final eye examination was 6 months in the past since she wears sun shades that wanted to be modified. No historical past of glaucoma or extreme tearing. No ear an infection or discharge. The scent is unbroken with no situations of epistaxis. No historical past of nasal polyps or an infection. Her final dental examination was in 2019. No dental issues equivalent to bleeding or ulceration. No problem swallowing or chewing.
SKIN: No historical past of damage, itching, or lesions.
CARDIOVASCULAR: No chest discomfort, ache, edema, or ache.
RESPIRATORY: No problem in respiration, sputum, nasal congestion.
GASTROINTESTINAL: No nausea, vomiting, or stomach ache.
GENITOURINARY: No modifications within the urinary patterns. LMP 12/29/2020
NEUROLOGICAL: The affected person denies headache, bladder management issues, and dizziness.
MUSCULOSKELETAL: No muscle or again ache, arthritis, arthralgia, ache, muscle or joint stiffness.
HEMATOLOGIC: No bleeding or bruising.
LYMPHATICS: The affected person denies a historical past of enlarged nodes.
PSYCHIATRIC: No historical past of melancholy, anxiousness, or suicidal ideation.
ENDOCRINOLOGIC: No historical past of polyuria.
ALLERGIES: The affected person denies a historical past of bronchial asthma.
O.
Bodily examination:
Very important indicators: B/P 120/80 left arm common siting cuff, P 76 common, T 98.7F orally, left-arm sitting, RR 18, Wt 113lbs, Ht four’Eight, BMI 21.
Normal: A&O*three, NAD, seems snug.
HEENT: PERRLA EOMI + extreme tearing on the eyes, drooping on the correct aspect of the face, and delicate nasolabial fold flattening.
Neck: Carotid no bruit.
Chest/lungs: CTA AP&L.
Coronary heart/Peripheral: RR with out murmurs.
ABD: Benign nabs*four no rebound
Muskuloskeletal: Symmetrical bone motion and no exceptional damage within the joints.
Neuro: CII IV grossly intact.
Pores and skin lymph nodes: No edema and palpable nodes.
Diagnostic checks:
MRI
CT scan
EMG
Bodily examination
Glasgow coma scale
NIH stroke scale
Diagnostic outcomes:
Main prognosis:
Bell’s palsy – The situation is a short lived or a everlasting situation or paralysis. The situation happens when the nerve controlling the facial muscle is compressed, infected, or swollen (Genizi et al., 2019). The affect on the nerve results in one aspect of the face drooping. Different signs embody dry eye, sensitivity to sound, and irregular style. Healthcare employees relate the situation to emphasize or different well being points that may undermine immunity and comprise the nerve controlling the facial muscle mass (Genizi et al., 2019). Healthcare employees prescribe Corticosteroids to cut back the irritation.
A.
Differential Diagnoses
Parotid tumor – The situation results in irritation of the jaw. Sufferers expertise no ache. Different signs embody numbness and lack of facial motion (Jin et al., 2019). Therapy of the situation is generally with surgical procedure to take away the tumor.
Lyme illness – The infectious situation is attributable to the Borrelia bacterium. The illness causes a bull’s eye sample and flu-like signs (Mead et al., 2019). Folks affected by the situation get well after taking antibiotics.
Tetanus – Tetanus is a critical situation attributable to bacterial toxins that have an effect on the nervous system. The impact results in painful muscle contractions. The life-threatening situation requires pressing medical therapy. In some instances, it might probably result in lockjaw (Kyu et al., 2017). Therapy includes managing the issues that may threaten life.
Mastoiditis – The situation impacts the mastoiditis bone within the ear. The illness happens as a consequence of failure to deal with ear infections. The life-threatening situation causes swelling, redness, fever, ache, and discharge (Loh et al., 2018). Medical practitioners prescribe antibiotics to deal with the an infection.
Stroke – The situation happens when the availability of oxygenated blood is disrupted. The disruption results in an inadequate provide of oxygenated blood, which is life-threatening. It’s a medical emergency that interferes with speaking, and strolling (Campbell et al., 2019). It could possibly trigger paralysis or numbness. Therapy includes a clot-buster which is liable for minimizing the injury on the mind cells.
Guillain-barre syndrome – The uncommon situation happens when the immune system assaults the nerves. The affect can have an effect on the perform of some nerves within the physique. In excessive instances, it might probably trigger paralysis (Esposito & Longo, 2017). Blood therapy and psychotherapy are most popular strategies of therapy.
References
Campbell, B. C., De Silva, D. A., Macleod, M. R., Coutts, S. B., Schwamm, L. H., Davis, S. M., & Donnan, G. A. (2019). Ischaemic stroke. Nature Critiques Illness Primers, 5(1), 1-22.
Esposito, S., & Longo, M. R. (2017). Guillain–Barré syndrome. Autoimmunity Critiques, 16(1), 96-101.
Genizi, J., Golan-Shany, O., Tarazov, T., Pechter, S., Assaf, N., Segal, I., … & Bamberger, E. (2019). Does herpes 6 an infection have a task in Bell’s palsy amongst youngsters and adolescents?. The Pediatric Infectious Illness Journal, 38(5), 481-483.
Jin, H., Kim, B. Y., Kim, H., Lee, E., Park, W., Choi, S., … & Jeong, H. S. (2019). Incidence of postoperative facial weak point in parotid tumor surgical procedure: a tumor subsite evaluation of 794 parotidectomies. BMC Surgical procedure, 19(1), 1-Eight.
Kyu, H. H., Mumford, J. E., Stanaway, J. D., Barber, R. M., Hancock, J. R., Vos, T., … & Naghavi, M. (2017). Mortality from tetanus between 1990 and 2015: findings from the worldwide burden of illness examine 2015. BMC Public Well being, 17(1), 1-17.
Loh, R., Phua, M., & Shaw, C. L. (2018). Administration of paediatric acute mastoiditis: systematic assessment. The Journal of Laryngology and Otology, 132(2), 96.
Mead, P., Petersen, J., & Hinckley, A. (2019). Up to date CDC suggestion for serologic prognosis of Lyme illness. Morbidity and Mortality Weekly Report, 68(32), 703-703.
Rainer, J., Schneider, J. Okay., & Lorenz, R. A. (2018). Ethical dilemmas in nursing: An integrative assessment. Journal of Medical Nursing, 27(19-20), 3446-3461.
