Assessing Neurological Symptoms
To do a comment to each post with two credible reference each comment with citation above 2013
Post 1
Patient Information:
XX, 20, Male
S.
CC: “intermittent headaches”
HPI: 20 year old male who complains of experiencing intermittent headaches, which diffuses all over his head. The great intensity and pressure occurs above the eyes and spreads to the nose, cheekbones, and jaw.
Location: Generalized headache
Onset: Unknown
Character: Pressure
Associated signs and symptoms: Greatest intensity above eyes and spreads to the nose, cheekbone, and jaw
Timing: Intermittent
Exacerbating/ relieving factors: Unknown
Severity: Unknown
Current Medications: Unknown
Allergies: Unknown
PMHx: Unknown
Soc Hx: Unknown
Fam Hx: Unknown
ROS:
GENERAL: Unknown
HEENT: Unknown
GENITOURINARY: Unknown
NEUROLOGICAL: Unknown
MUSCULOSKELETAL: Unknown
LYMPHATICS: Unknown
PSYCHIATRIC: Unknown
ALLERGIES: Unknown
O.
HEENT: Unknown
GENITOURINARY: Unknown
NEUROLOGICAL: Unknown
MUSCULOSKELETAL: Unknown
LYMPHATICS: Unknown
Diagnostic results:
Mental Status Screen: The cause of a headache could have a life-threatening cause. Ruling out life threatening causes first is the priority. Completing a mental status screen first is imperative to ensure the patient is fully orientated and able to provide a accurate health history (Dains, Baumann, & Scheibel, 2016, p. 221).
Determine the presence of a trauma. Bleeding can occur which can result in a sudden change in mental status (Dains, Baumann, & Scheibel, 2016, p. 223).
Determine the presence of any underlying chronic disease process. Patients who are immunocompromised are more likely to acquire an infection that could affect the brain. Furthermore, a headache could result from an electrolyte imbalance, blood sugar change, or hypercapnia to name a few (Dains, Baumann, & Scheibel, 2016, p. 223).
Complete blood count (CBC) with differential: Ordered to detect any abnormal lab findings (Dains, Baumann, & Scheibel, 2016, p. 229).
Computed Tomography Scan (CT): Will detect any intracranial disease and should be completed with a new onset headache or in the presence of abnormal neurological findings (Dains, Baumann, & Scheibel, 2016, p. 229).
Lumbar Puncture: Will evaluate the cerebrospinal fluid pressure and can detect altered components, such as lymphocytes, glucose, protein, and bacteria. Would aid in detecting an infection of the central nervous system (Dains, Baumann, & Scheibel, 2016, p. 229).
Erythrocyte Sedimentation Rate (ESR): Elevated in the presence of inflammation and is utilized when arteritis is suspected (Dains, Baumann, & Scheibel, 2016, p. 229).
Skull Radiography- Utilized post trauma to view intracranial structures (Dains, Baumann, & Scheibel, 2016, p. 229).
A.
Differential Diagnoses:
Tension-Type Headache (TTH): Most common adulthood headache. Often related to muscle contraction that could be caused by hunger, depression, or stress. Sign and symptoms include bilateral, generalized, or localized pain that distributes in the frontotemporal region. The level of pain can be mild to moderate with a throbbing, tight, or pressurized pain with a gradual onset. Duration is different for every patient, but can range from hours to months (Dains, Baumann, & Scheibel, 2016, p. 230; Kim et al., 2017)
Mixed Headache: Occurs from muscular and vascular contraction. The pain is often described as throbbing with a constant pain while the patient is awake. Further symptoms include tightness, pressure, and muscle contraction. This is a possible diagnosis, but not expected due to the patient not complaining of muscle contraction (Dains, Baumann, & Scheibel, 2016, p. 230).
Sinusitis: Would be consider a secondary headache because it is caused by another disease process. Sore throat, postnasal discharge, and facial pain are often seen in conjunction with the headache. Specifically, pain occurs over the affected sinuses. This is a possible diagnosis, but additional respiratory symptoms would be expected if it were the cause (Dains, Baumann, & Scheibel, 2016, p. 230).
Cluster headache: Onset is typically abrupt, occurs at night, and seen mostly in men. Pain is described as as severe, burning, piercing, or neuralgic. An episode can be 15 minutes to 2 hours at a time. The patient will experience several episodes in a cluster of time. Each cluster ranges from days to weeks. Other symptoms seen with a cluster headache are ipsilateral rhinorrhea, conjunctivitis, facial sweating, ptosis, and eyelid edema. Headaches are brought on by the consumption of alcohol, stress, and heat or wind exposure. Overall, the patients clinical presentation does not match cluster headaches (Dains, Baumann, & Scheibel, 2016, p. 230; Weaver-Agostoni, 2013).
Dental disorders: The presence of a tooth abscess or nerve root dysfunction could cause a headache with associate facial pain. The oral inspection of the mouth may reveal redness or area of infection. The oral mucosa will also be tender to touch. This is a possible diagnose for out patient, but not likely given we do not know the results of his oral exam (Dains, Baumann, & Scheibel, 2016, p. 230).
