Nursing homework help

Nursing 6512 Advanced Health Assessment & Diagnostic Reasoning

Episodic/Focused SOAP Note Review of Case #3 Week 9 Initial Post

Patient Initials: K. T. Age: 33 Gender: F Ethnicity: African American

SUBJECTIVE DATA:

Chief Complaint (CC): “Drooping on the right side of face”

History of Present Illness (HPI): MH is a 33-year-old Caucasian female

presents to the office today with right side facial drooping that she

observed when she woke up this morning. She says that her right eye has

been watering constantly, and that she can’t stop drooling out of the right

side of her mouth. She denies any pain.

Medications:

Ibuprofen 200mg-2 PO as needed

Tylenol 325mg-2 PO every 4 hours as needed

Woman’s Multivitamin daily

Allergies: No Known Allergies

Past Medical History (PMH): Diagnosed with asthma when she was a

child. All immunizations are up to date. Denies ever having any surgeries

or hospitalizations.

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Social History: K. T. is a heterosexual, sexually active individual who

lives with her husband and children. She denies any tobacco, alcohol or

illicit drug use & wears her seatbelt whenever operating a motor vehicle.

She enjoys time with her family, evening walks with her children when

weather permits and front porch sitting with a good book in hand. She

denies any issues with sleep and reports getting approximately 8-10 hours

of sleep a night.

Family History: Both of her parents are still living. Her father is 55 with a

history of arthritis and hypertension. Her mother is 54 without any

significant health history. Her younger sister, age 30, does not have any

significant health history. She has two children, ages 7 & 5 who are

healthy.

Review of Systems (ROS):

General: No unexplained weight loss or weight gain, no decreased

appetite, no fever, chills or fatigue

HEENT: No blurred or loss of vision, no loss of hearing, hearing difficulty

or ringing in ears, no congestion, runny nose, sore throat or hoarseness,

no swelling/tenderness in lymph nodes.

Skin: No changes in skin such as rashes, lesions dryness or persistent

itching

Respiratory: No SOB, cough or sputum production.

Cardiovascular: No chest pain, pressure or palpitations, no edema or

pain with walking

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Gastrointestinal: No change in bowel habits, indigestion,

nausea/vomiting or diarrhea. No abdominal pain or tenderness

Genitourinary: No burning with urination, itching, difficulty starting

stream or increased frequency

Musculoskeletal: No muscular or joint pain

Hematologic: No anemia or bleeding, not easily bruised

Endocrinological: No heat or cold intolerances, no sweating, no polyuria

or polydipsia.

Neurological: No dizziness, LOC, or headaches. Moves all extremities

without tremors

Psychiatric: No mental illness, depression or anxiety

OBJECTIVE DATA:

Physical Exam:

Vital Signs: Temp: 98.2. Pulse: 82, Respirations: 20 and non-labored.

SpO2: 100% on RA, BP: 116/72 mmHg. Weight 140lbs. H: 5’8’ BMI: 21.3

General: Well-groomed and well-nourished, answering questions

appropriately

HEENT: Normocephalic, atraumatic, wears glasses, no hearing difficulties,

good oral hygiene, no swelling/tenderness in lymph nodes.

Skin: Intact, appropriate for ethnicity, no rashes, lesions dryness

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Cardiovascular: No chest pain or palpitations. RRR without murmur, no

edema, pulses palpable bilaterally to lower extremities, cap refill greater

than 3 seconds

Respiratory: No SOB, chest expansion equal and symmetric with clear

lung sounds, no cough or sputum production.

Gastrointestinal: No nausea, vomiting, diarrhea, or discomfort,

nondistended, nontender, BS present, and normoactive x4, no

organomegaly.

Genitourinary: Genitalia not examined. No dysuria or incontinence.

Neurological: AOx4, + for paresis on right side of face, + for difficulty

making facial expressions, moves all extremities without tremors or

weakness

Psychiatric: Calm, cooperative, concerned about symptoms

Allergic/Immunologic: No known allergies, no immune deficiencies.

ASSESSMENT:

Lab Tests:

Complete blood count to assess for possible infectious causes

Enzyme-linked immunosorbent assay [ELISA] or Enzyme immunoassay

[EIA] to assess for Lyme’s

Diagnostics:

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Computed Tomography (CT) or magnetic resonance imaging (MRI) to

identify infection, inflammation, tumor, fractures, or other potential

causes for facial nerve involvement.

Electromyography (EMG) testing – A test in which a needle electrode is

inserted into affected muscles to record both spontaneous

depolarizations and the responses to voluntary muscle contraction.

Electroneuronography (ENoG) testing (neurophysiologic studies) – A

test used to examine the integrity of the facial nerve, in which surface

electrodes record the electrical depolarization of facial muscles

following electrical stimulation of the facial nerve.

Glasgow Coma Scale & NIH Stroke Scale – to rule out stroke

Cerebrospinal fluid (CSF) analysis – to identify the presence of

increased protein and white blood cells; for this test, a needle is

inserted into the spine between vertebrae and a small amount of fluid

is withdrawn. While some protein is normally present, an increased

amount without an increase in the white blood cells in the CSF may be

indicative of Guillain-Barré syndrome.

Diagnosis:

Bell’s Palsy – According to Baugh, et al (2013). Bell’s Palsy, named

after the Scottish anatomist, Sir Charles Bell, is the most widely

recognized acute mono-neuropathy, or on the other hand issue

influencing a solitary nerve, and is the most normal determination

related with facial nerve weakness/loss of motion. Bell’s Palsy is a

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sudden one-sided facial nerve paresis (weakness) or loss of motion

(complete loss of development) of obscure reason. The condition

prompts the fractional or complete failure to deliberately move facial

muscles on the influenced side of the face. Albeit commonly self-

constrained, the facial paresis/loss of motion that happens in Bell’s

palsy may cause noteworthy brief oral ineptitude and a powerlessness

to close the eyelid, prompting potential eye damage.

Differential Diagnoses:

Facial Nerve Schwannomas – Facial nerve schwannomas (FNSs) are

slow-growing developing favorable tumors that can occur along any

section of the facial nerve. Indications can be variable relying upon the

size and area of the tumor, yet usually incorporate facial paresis,

hearing loss, and vestibular side effects (Jacob, Driscoll, & Link, 2012).

Guillain-Barre Syndrome: Typically starts as paresthesia and

weakness and continuously rising, manifestations incorporate facial

droop, diplopia, dysphagia, dysarthria, and pupillary aggravations

(Andary, 2017).

Mastoiditis – a bacterial contamination of the temporal bone and

gives the accompanying side effects; otalgia, otorrhea, swelling,

delicacy, and facial paralysis is an intra-transient complication (Devan,

2016).

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Stroke – Strokes often present with facial drooping, but it usually

affects one side of the body. If a patient can raise their eyebrows

normally and symmetrically but the lower part of their face is

paralyzed the health care provider will need to rule out a stroke (EBM

Consult, 2015).

Lyme disease – Lyme Disease is a disease caused by bacteria that

ticks can carry. It can cause bell’s palsy because advanced symptoms

of Lyme disease can affect the nervous system (Roth & Cirino, 2016).

References

Andary, M. (2017). Guillain-Barre Syndrome. Retrieved

fromhttp://emedicine.medscape.com

/article/315632-overview

Baugh, R. F., Basura, G. J., Ishii, L. E., Schwartz, S. R., Drumheller, C. M.,

Burkholder R., Deckard, N. A.,

Dawson, C., Driscoll, C. M., Gillespie, B., Gurgel, R. K., Halperin, J.,

Khalid, A. N., Kumar, K. A., Micco, A., Munsell D., Rosenbaum, S., and

Vaughan, W. (2013). Clinical Practice Guideline: Bell’s Palsy.

Otolaryngology–Head and Neck Surgery. 149(3), pp. S1 – S27.

https://doi.org/10.1177

/0194599813505967

Devan, P. P. (2016). Mastoiditis clinical presentation. Retrieved from

http://emedicine.medscape.com/

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article/2056657-clinical#b3

EBM Consult. (2015). Stroke vs. bell’s palsy. Retrieved from

http://www.ebmconsult.com/articles/anatomy

stroke-vs-bells-palsy

Hinckley, A. F., Connally, N. P., Meek, J. I., Johnson, B. J., Kemperman, M. M.,

Feldman, K. A.,

White, J. L., & Mead, P. S. (2014). Lyme Disease Testing by Large

Commercial Laboratories in the United States. Clinical Infectious

Diseases, (59)5, pgs. 676–681, https://doi.org/10.1093/cid/ciu397

Jacob, J. T., Driscoll, C. L. W., & Link, M. J. (2012). Facial Nerve Schwannomas

of the Cerebellopontine

Angle: The M