Discuss: Drooping of Face

Discuss: Drooping of Face

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Patient Information:

Initials: G.M.

Age: 33 years

Sex:  Female

Race:  Hispanic

Subjective

CC (chief complaint): “Drooping of the face.”

HPI: G.M is a 33-year-old Hispanic female presenting with a chief complaint of drooping of the face. She states that she experienced the face droop in the morning on the right side of her face. She also reports symptoms of excessive lacrimation and drooling, which occur on the right side.

Current Medications: Albuterol inhaler PRN for Asthma attacks.

Allergies: Allergic to dust mites, pollen, and smoke. No known drug allergies.

PMH: Last T.T. was four years ago. Last Flu shot- 7 months ago. She has a history of asthma; her last Asthma attack was at the age of 28 years. History of cesarean section, seven years ago due to Meconium Aspiration. No history of psychiatric disorders or gynecologic disorders.

Soc Hx: The patient is married and lives with her husband and two children aged 10 and 7 years. G.M is a primary school teacher teaching Art studies in a private school. Hobbies include painting and watching theatre arts. She takes alcohol, white wine 2-3 glasses occasionally but denies using tobacco. Her support system is her family and sister. The patient reports attending annual health check-ups and having daily morning exercises.

Fam Hx: The patient’s elder sister and mother have Type 1 DM. The paternal grandmother had cervical cancer, and the paternal grandfather had Renal failure.  Her children are alive and well.

ROS:

GENERAL:  Negative for body weakness, low energy levels, fever, or weight changes.

HEENT:  Head: Positive for drooling on the right side. Denies headache or head injury. Eyes:  Positive for excessive lacrimation on the right eye. Negative for diplopia, visual loss, or eye pain.  Ear: Denies ear discharge, hearing loss, or ear pain. Nose: Negative for sneezing, nasal congestion, nasal drip, or epistaxis. Throat: Positive for drooling on the right side. Denies dental pain or swallowing difficulties.

CARDIOVASCULAR:  Denies palpitations, ankle edema, chest pain, chest pressure, shortness of breath during activity, or history of elevated B.P.

RESPIRATORY:  Negative for a history of cough, bloody sputum, shortness of breath, or chest pain.

GASTROINTESTINAL:  No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: Positive for one-sided face drooping and paralysis of facial muscles. Reports numbness on the right side of the face. Denies having a history of headache, syncope, dizziness, fainting spells, or tingling sensations in the lower extremities.

ALLERGIES:  Positive history of asthma.

Objective

Physical exam:

Vital Signs: BP- 114/70; HR- 84; RR- 20; Temp- 98.24F

Ht- 5.4 ft; Wt- 134; BMI-23.0

General: Female patient not in acute distress. She is neat and appropriately dressed.  Anxious-looking and maintains minimal eye contact.

HEENT: Head: Mask-like and sagging face. Unable to wrinkle the forehead, grimace, and smile on the right side.  Eye: Unable to completely close the right eye and the lower lid sag. Low eyebrow position noted.  Excessive lacrimation in the right eye. Ear: No discharge observed. Tympanic membranes clear on inspection. Nose: Nasal septum well-aligned. Throat: Drooling on the right side. Pink ad moist mucous membranes. Tonsillar glands are non-inflamed.

Cardiovascular: No edema or neck vein distention. The heart rate is regular. S1 and S2 present. No abnormal heart sounds present on auscultation.

Respiratory: Smooth and regular respirations with no chest indrawings. On auscultation, lungs are clear with no adventitious breath sounds.

Neurological: Unilateral paralysis of facial muscles. Impaired taste sensation.

Diagnostic Tests:

Head CT scan: A head CT scan will be requested to confirm if the patient is having a stroke. If she has a stroke, the CT scan will identify the cause of the stroke, that is, if hemorrhagic or ischemic (Chugh, 2019). A Head CT scan is the primary diagnostic test used to diagnose stroke. A CT scan indicates the size and location of the lesion and differentiates between hemorrhagic and ischemic stroke (Chugh, 2019).

Cerebral angiography: A cerebral angiography will be used to measure cerebral flow and determine if the symptoms are due to alteration in cerebral circulation (Chugh, 2019).

Fasting Blood Sugar (FBS): FBS is recommended in patients suspected of having Bell’s palsy since it usually occurs in more than 10% of persons with Diabetes mellitus (Heckmann et al., 2019). As a result, FBS is performed in individuals with additional risk factors for diabetes, such as obesity, age above 30 years, and a positive family history of diabetes.

Assessment

Differential Diagnoses

Bell’s Palsy:

Bell’s  Palsy, also known as Facial paralysis, refers to an acute paralysis of cranial nerve VII, the facial nerve. It is the most prevalent disorder of the cranial nerves (Heckmann et al., 2019). A vital criterion for facial nerve function includes hearing, lid closure, secretion of tears and saliva, and taste. Bell’s  Palsy manifests with paralysis of all facial muscles on the affected side and a drawing sensation. Patients can also present with drooling from the corner of the mouth as an initial symptom (Heckmann et al., 2019). A person with a rapid onset of unilateral facial weakness most probably has Bell’s palsy. In Bells’ palsy, the person cannot completely close the eye on the affected side. They have a low eyebrow position and may have excessive lacrimation. They cannot smile, whistle, wrinkle the forehead, or grimace (Heckmann et al., 2019). Besides, the face looks mask-like and sags, also known as facial paralysis. Taste is also usually impaired to some extent.

Bell’s palsy is a presumptive diagnosis for this case based on pertinent positive findings of unilateral facial paralysis evidenced by facial drooping, inability to completely close the right eye, sagging of the lower eyelid, and low eyebrow position. The patient also presents with other typical symptoms of  Bell’s palsy, such as drooling, impaired taste sensation, and excessive lacrimation.

Stroke

Stroke is a focal neurologic deficit with sudden onset due to an alteration in circulation or cerebral ischemia. It can result in irreversible brain damage (Chugh, 2019). Stroke is characterized by an abrupt development of clinical signs of focal disturbance of cerebral function that can cause death.  When a stroke occurs, functions controlled by the affected part of the brain, such as sensation and movement, are impaired or lost (Chugh, 2019). Stroke causes central facial palsy. Clinical manifestations of ischemic stroke include a sudden onset of unilateral paralysis, double vision, impaired speech and language, impaired right/left discrimination, facial droop, altered level of consciousness (Chugh, 2019). However, stroke only causes paralysis of the lower half of the face.

Pertinent positive findings consistent with Ischemic include unilateral facial paralysis and right-side drooling. However, the patient presents with dysfunction on the upper half of the face, making Strokes an unlikely diagnosis for this patient. Besides, the patient has no history of high blood pressure, and the blood pressure at presentation is 114/70, which is within the normal range. Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is an autoimmune disorder affecting peripheral nerves and nerve roots and is mostly triggered by infections. It is considered the leading cause of acute flaccid paralysis (Leonhard et al., 2019). The paralysis usually occurs bilaterally. GBS manifests with weakness of upper or lower limbs bilaterally. In addition, reflexes are diminished or absent in most individuals at presentation. Patients also present with bilateral facial weakness, paresthesia, and weakness of cervical, pharyngeal, and brachial muscles (Leonhard et al., 2019). The patient’s symptoms consistent with GBS presentation include facial paralysis that leads to facial drooping.

Lyme disease

Lyme disease is a vector-borne multisystem infection caused by Spirochete Borrelia burgdorferii. Lyme disease is one of the causes of peripheral nerve palsies that can result in facial paralysis (Gasmi et al., 2017). Neurological manifestations of early disseminated Lyme disease include facial palsy and symptoms of meningitis. Persons with Lyme disease mostly have a history of tick exposure or have been exposed to an area where Lyme disease is endemic (Gasmi et al., 2017). Lyme disease also presents with a rash and joint pain. Lyme disease is a differential diagnosis based on the patient’s manifestation of facial paralysis. However, it is a less likely primary diagnosis since the patient has no history of tick exposure or symptoms of tick bite such as a rash.

Sarcoidosis

Sarcoidosis refers to a granulomatous disorder of unknown etiology that affects any organ, but the lung is the most affected organ. Sarcoidosis develops over time, with growths referred to as granulomas developing in the lungs (Ungprasert et al., 2019). The granulomas are composed of macrophages, lymphocytes, epithelioid cells, and giant cells. Neurologic involvement is termed neurosarcoidosis, which affects any cranial nerve (Ungprasert et al., 2019). However, cranial nerves II, VII, and VIII are the most commonly affected. The involvement of cranial nerve VII, which accounts for approximately 10% to 25% of all neurosarcoidosis cases, causes facial palsy that is either unilateral or bilateral (Ungprasert et al., 2019). Sarcoidosis is a differential diagnosis based on a pertinent positive finding of unilateral facial palsy.

References

Chugh, C. (2019). Acute Ischemic Stroke: Management Approach. Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine, 23(Suppl 2), S140–S146. https://doi.org/10.5005/jp-journals-10071-23192

Gasmi, S., Ogden, N. H., Leighton, P. A., Adam-Poupart, A., Milord, F., Lindsay, L. R., Barkati, S., & Thivierge, K. (2017). Practices of Lyme disease diagnosis and treatment by general practitioners in Quebec, 2008-2015. BMC family practice, 18(1), 65. https://doi.org/10.1186/s12875-017-0636-y

Heckmann, J. G., Urban, P. P., Pitz, S., Guntinas-Lichius, O., & Gágyor, I. (2019). The Diagnosis and Treatment of Idiopathic Facial Paresis (Bell’s Palsy). Deutsches Arzteblatt international, 116(41), 692–702. https://doi.org/10.3238/arztebl.2019.0692

Leonhard, S. E., Mandarakas, M. R., Gondim, F., Bateman, K., Ferreira, M., Cornblath, D. R., van Doorn, P. A., Dourado, M. E., Hughes, R., Islam, B., Kusunoki, S., Pardo, C. A., Reisin, R., Sejvar, J. J., Shahrizaila, N., Soares, C., Umapathi, T., Wang, Y., Yiu, E. M., Willison, H. J., … Jacobs, B. C. (2019). Diagnosis and management of Guillain-Barré syndrome in ten steps. Nature reviews. Neurology, 15(11), 671–683. https://doi.org/10.1038/s41582-019-0250-9

Ungprasert, P., Ryu, J. H., & Matteson, E. L. (2019). Clinical Manifestations, Diagnosis, and Treatment of Sarcoidosis. Mayo Clinic proceedings. Innovations, quality & outcomes, 3(3), 358–375. https://doi.org/10.1016/j.mayocpiqo.2019.04.006

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.

To prepare:

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.

Note: Before you submit your initial post, replace the subject line (“Discussion – Week 9”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.

By Day 3

Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in 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.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.

Assignment 1: Differential Diagnosis for Skin Conditions

Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.

In this Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.

To prepare:

Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Assignment.
Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
Consider which of the conditions is most likely to be the correct diagnosis, and why.
Download the SOAP Template found in this week’s Learning Resources.

To complete:

Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format, rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to fivepossible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least 3 different references from current evidence based literature.

Week 6 assignment

Assesment 1: Assessing the Abdomen

A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CAT scan. The CAT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping.

Because of a high potential for misdiagnosis, determining the precise cause of abdominal pain can be time-consuming and challenging. By analyzing case studies of abnormal abdominal findings, nurses can prepare themselves to better diagnose conditions in the abdomen.

In this assignment, you will analyze a SOAP note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

Abdominal Assessment

SUBJECTIVE:

CC: “My stomach hurts, I have diarrhea and nothing seems to help.”

HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.

PMH: HTN, Diabetes, hx of GI bleed 4 years ago

Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs

Allergies: NKDA

FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD

Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

OBJECTIVE:

VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs

Heart: RRR, no murmurs

Lungs: CTA, chest wall symmetrical

Skin: Intact without lesions, no urticaria

Abd: soft, hyperctive bowel sounds, pos pain in the LLQ

Diagnostics: None

ASSESSMENT:

Left lower quadrant pain

Gastroenteritis

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

To prepare:

With regard to the SOAP note case study provided:

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.

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.

To complete:

Analyze the subjective portion of the note. List additional information that should be included in the documentation.

Analyze the objective portion of the note. List additional information that should be included in the documentation.

Is the assessment supported by the subjective and objective information? Why or Why not?

What diagnostic tests would be appropriate for this case and how would the results be used to make a diagnosis?

Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least 3 different references from current evidence based literature.

Discuss: Drooping of Face

Discuss: Drooping of Face