Discussion: Assessing Neurological Symptoms

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Discussion: Assessing Neurological Symptoms

Discussion: Assessing Neurological Symptoms

 

Patient Information:

Initials: JH                  Age: 33 years old                    Sex: Female                Race: Hispanic

S.

CC: “The right side of my face has been dropping since morning.”

HPI: JH is a 33-year-old Hispanic female who came to the hospital complaining of her right face ‘drooping.’ She claims that the feeling started in the morning on the same day that she came to the hospital. She also complains of excessive tearing and drooling on the whole of her right side. She is however in no pain.

Location: right side of the face

Onset: in the morning

Character: drooping face

Associated signs and symptoms: excessive tearing and drooling on her right side

Timing: In the morning

Exacerbating/ relieving factors: none has been mentioned

Severity: not specified

Current Medications: None

Allergies: No known allergies to drugs, food or any environmental factor.

PMHx: No history given. No surgical history.

Soc Hx: Occupational and major hobbies in addition to family status has not been provided.

Fam Hx: Family history has not been provided.

ROS:

GENERAL:  Denies weight loss, chills, fever, fatigue or general weakness.

HEENT:  Eyes: Confirms excessive tearing.  Denies visual loss, double vision, blurred vision, or yellow sclerae. Ears, Nose, Throat: Denies, hearing loss, congestion, sneezing, sore throat or runny nose.

SKIN: Denies itching or skin rash

CARDIOVASCULAR: Denies chest pain, chest discomfort or chest pressure. No edema or palpitations.

RESPIRATORY: Denies breathing problems, shortness of breath, sputum or cough.  No shortness of breath, cough or sputum.

GASTROINTESTINAL: Denies nausea or vomiting, diarrhea or anorexia. Denies abdominal pain or bleeding.

GENITOURINARY: Denies burning on urination, painful urination or excessive urine frequency.

NEUROLOGICAL: Confirms drooping of the right side of the face. Confirms drooling on her right side. Denies headache, syncope, dizziness, ataxia, paralysis. Denies any change in bladder or bowel control.

MUSCULOSKELETAL: Denies muscle or joint pain or stiffness.

HEMATOLOGIC: Denies bleeding, bruises or history of anemia.

LYMPHATICS: Denies enlarged lymph nodes or any history of organomegaly.

PSYCHIATRIC: Denies any history of anxiety, depression or mania.

ENDOCRINOLOGIC: Denies excessive sweating, excessive cold or heat intolerance. Denies polydipsia or polyuria.

ALLERGIES: Denies any history of asthma attacks, eczema, hives, rhinitis or any allergic reactions.

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O.

Physical exam:

GENERAL: The patient is fatigued with general body weakness. Fever & chills are also present. No weight gain or weight loss.

HEAD: Her head is normocephalic and atraumatic with no injury

EENT:  Eyes: white sclera, pinkish conjunctiva, no jaundice or pallor. Presence of excessive tearing in the right eye, no movement on

Discussion Assessing Neurological Symptoms

Discussion Assessing Neurological Symptoms

the eyebrows, eyelid opening is normal; lower lid is sagging. Ears, Nose, Throat: No hearing problems, sneezing, running nose, sore throat or congestion. The nasolabial fold is absent on the right side. Presence of drooling on her right side, no movement of lips and mouth slightly open on the left side.

SKIN:  Normal warm skin with no lesions, itching or dryness.

CARDIOVASCULAR: No murmurs. Heart rhythm and heart rate is normal, with good S1 &S2 sound and no S3 & S4. No signs of peripheral edema.

RESPIRATORY:  No breathing problems, respiration is even and unlabored. No cough, sputum or shortness of breath.

GASTROINTESTINAL: soft abdomen with no tenderness on palpation. Presence of bowel sounds in all of the four quadrants.

NEUROLOGICAL: Paralysis of the right facial nerve.

MUSCULOSKELETAL:  ROM, no joint pain, back pain or stiffness.

LYMPHATICS:  No signs of enlarged lymph nodes.

Diagnostic results: unilateral, single episodes that involve all the nerve branches is an indication of Bell’s palsy. Consequently, studies show that unequal distribution of weakness on different zones of the face on physical examination suggests Bell’s palsy (Eviston et al., 2015). This condition occurs at any age above two years, but most commonly experienced by individuals between the age of 15 to 45 years. It is also important to check for the presence or absence of other associated symptoms such as dry eyes, synkinesis, and pain to be able to rule out other differential diagnoses. From the physical examination, the patient is suspected of having an acute unilateral facial palsy which is a significant indication of Bell’s palsy. Other imaging tests such as needle electromyography (EMG), CT scan, and MRI are necessary for ruling out other conditions with the same symptoms (Wiggins, & Ashok, 2015). Serological test for Borrelia Burgdorferi should also be requested, such that a negative result will indicate bell’s palsy as a possible diagnosis.

A.

Differential Diagnoses:

  1. Bell’s Palsy: Bell’s palsy is a neurological condition characterized by an acute unilateral palsy of the peripheral facial nerve. The diagnosis of this condition is normally confirmed in patients of whom medical history and physical examination are unremarkable, including deficits that affect all the zones of the face equally, and fully resolve within three days. Bell’s palsy leads to a sudden weakness of the facial muscles temporarily, which makes one side of the face to droop (Eviston et al., 2015). The patient in the assigned case scenario is positive for most of the indicating signs and symptoms of Bell’s palsy making this condition the most appropriate diagnosis.
  2. Lyme disease: This is a bacterial infection that is transmitted by a vector, infected black-legged tick which is commonly referred to as the deer tick. Prolonged infection causes injury to the neurological system that may present as paralysis on one side of the face, weakness in both limbs, numbness, and impaired movement of muscles (Wormser et al., 2015).
  3. Facial nerve schwannoma: This is a type of a primary benign intracranial tumor of the vestibular nerve of the myelin-forming calls. The main sign and symptoms of this condition is the slow progression of facial nerve paralysis which causes drooping of the face, which the patient in this case study is positive for (Slattery, 2014). Additional symptoms include hearing loss, vestibular symptoms, pain, and tinnitus.
  4. Idiopathic orofacial granulomatosis (Melkersson-Rosenthal syndrome): This condition is characterized by insidious and slowly progressive paralysis of the facial nerve. The parotid mass is usually palpable upon physical examination (Miest et al., 2017).
  5. Cerebrovascular accident (CVA): This condition is commonly known as stroke, and it is caused by blockage or rupture of blood vessels supplying blood to the brain. It is characterized by numbness and paralysis in the face which the patients positive for, among other symptoms (Karliński, Gluszkiewicz, & Członkowska, 2015). These symptoms include difficulty in walking, loss of balance and coordination, dizziness, blurred or darkened vision, a sudden headache that is accompanied by nausea and vomiting and difficulty in speaking.

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