Case Study Assignment: 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 Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

To Prepare

• By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
• Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style 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.

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.

The Case Study Assignment

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.

 

Case Scenario

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.

Episodic/Focused SOAP Note Template

Patient Information:

Initials – Miss G.N , Age- 33 Sex- Female, Race- Caucasian

S.

CC Miss G.N presents to the office with sudden right side drooping, drooling and excessive tearing.

HPI:

Location: right side face

Onset: sudden

Character: excessive tearing and sudden drooping, drooling

Associated signs and symptoms: drooling and tearing

Timing: all the time

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: Aleve

Allergies: No known food or drug allergies

PMHx: Denies any past major illness or hospitalization. Her immunization is upto date with her last jab being an influenza shot which she received in December.

Soc Hx: The patient is a cashier in a local convenience store. Her major hobbies include hiking and driving. She has a strong support system from her siblings, parents and friends. She also enjoys cooking.

Fam Hx: The patient is the only child. Both of her parents are live. Her parents are alive too and living in the neighborhood.

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:  No burning on urination.

NEUROLOGICAL:  Right side drooping, drooling and excessive tearing. 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. Denies frequency in urination, excessive thirst and excessive hunger. AAO X 4, well groomed, denies fever, chills, or fatigue. Appears tired from lack of sleep.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.

O.

Physical exam:

Vital signs: Temp= 98.2 F, RR= 16, PR= 78, 02 sat= 98%, Weight= 145 lbs, Height = 5’7’

General: Alert, oriented x 3

Neurological: right side drooping, dropping and excessive tearing

Tympanic membranes intact, no changes in hearing, no discharge from ears. The nose is congested, and itchy; the nasal mucosa is pale and boggy with thin clear secretions, and nasal turbinates are slightly enlarged. The throat is mildly erythematous, with no enlarged tonsils.

Diagnostic results: Cerebrospinal fluid (CSF) for diagnosis of Bell’s palsy (Henkel et al., 2017).

A.

Differential Diagnoses

Bell’s palsy

Bell’s palsy is a condition that affects the facial nerve causing muscle weakness on one side of the face. Signs and symptoms include corner drooping of the mouth, facial creasing, and unfurrowing of the forehead (Somasundra & Sullivan, 2017). Similarly, the lower eyelids sag while the eyelids will rarely close, there is dribbling of saliva and an altered sensation of the affected side of the eye.

Guillain Barre Syndrome

Gullaine barre syndrome is an acute polyneuropathy affecting 2 out of 100,000 people yearly. The condition is most common among men as compared to women. The three subtypes of the condition are inflammatory demyelinating polyneuropathy, axonal cute motor neuropathy and acute sensory axonal neuropathy and the third one is miler fisher syndrome (Leonhard et al., 2019). Patients experience weakness of the muscles peaks at 2 weeks for 50 percent. The degree of weakness among patients occurs differently on the affected muscles which range from paralysis of the tongue, swallowing, and facial muscles. Patients with this condition have issues of severe deep and leg aches.

Ramsay hunt syndrome

Ramsay Hunt syndrome is a condition that of herpes zosters that appears after the reactivation of the varicella-zoster virus at the geniculate ganglion. The condition may affect the ear, face, head, and neck.  In patients with Ramsay Hunt syndrome, facial nerve palsy manifests through the weakness of the affected side (Jeon & Lee, 2018). Other symptoms include decreased forehead wrinkling, drooping in the corner of the mouth, and inability to close the ears. It is also important to note that loss of motor control of the facial eye could result in excessive dryness which exposes ulceration of cataracts. Similarly, the flow of saliva is limited on the affected sides.

Lyme disease

Lyme disease refers to a disease that affects the nervous system. If the cranial nerve is involved, it results in facial droop on either or both sides (Wormser et al., 2018). Signs and symptoms include pain, weakness, numbness, meningitis symptoms, and visual disturbances.

Acute suppurative otitis media

Facial nerve palsy refers to complications of the acute suppurative otitis media (ASOM). Facial nerve paralysis is caused by the alterations of the middle ear’s microenvironment such as acute inflammation osteitis as well as elevated pressure.

 

 

 

References

Henkel, K., Lange, P., Eiffert, H., Nau, R., & Spreer, A. (2017). Infections in the differential diagnosis of Bell’s palsy: a plea for performing CSF analysis. Infection, 45(2), 147-155.

Jeon, Y., & Lee, H. (2018). Ramsay Hunt syndrome. Journal of dental anesthesia and pain medicine, 18(6), 333–337. https://doi.org/10.17245/jdapm.2018.18.6.333

Leonhard, S. E., Mandarakas, M. R., Gondim, F. A., Bateman, K., Ferreira, M. L., Cornblath, D. R., … & Jacobs, B. C. (2019). Diagnosis and management of Guillain–Barré syndrome in ten steps. Nature Reviews Neurology, 15(11), 671-683.

Somasundara, D., & Sullivan, F. (2017). Management of Bell’s palsy. Australian prescriber, 40(3), 94–97. https://doi.org/10.18773/austprescr.2017.030

Wormser, G. P., McKenna, D., Scavarda, C., & Karmen, C. (2018). Outcome of facial palsy from Lyme disease in prospectively followed patients who had received corticosteroids. Diagnostic microbiology and infectious disease, 91(4), 336-338.