Posted: June 14th, 2023

72-year-old female patient with a history of hypertension

Assessing, Diagnosing, and Treating Head, Neck, and Face Disorders

Head, neck, and face disorders are common, and thus you will likely care for elderly patients with these disorders. In your role as an advanced practice nurse, you must be able not only to correctly assess and diagnose patients but also help patients manage the disorder by planning necessary treatments, assessments, and follow-up care.

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To prepare:

Review the case study provided by your Instructor.
Reflect on the patient’s symptoms and aspects of disorders that may be present.
Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
Access the Focused SOAP Note Template in this week’s Resources.
The Assignment:

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition
Case study
72 year old Dickson a female patient seen in Office with clear speech and history of headache, denies nausea. She denies any visual or auditory hallucinations. tearing and an itchy, burning sensation in both eyes. Headaches have become more debilitating recently. some neck pain. The patient states this is not a new problem, but it has worsened in the past week and is affecting her vision. The patient complains that her eyes are dry. Her visual acuity is 20/50 OU, 20/40 OD, 20/50 OS. The eyelids are erythematous and edematous with yellow crusting around the lashes She denies any suicidal thoughts or ideations. She is alert and oriented to person, partially oriented to place but is disoriented to time and place. Review of System and Physical Exam findings are negative other than stated.
PMH: Hypertension, Hyperlipidemia, Osteoporosis
Vital Signs: 98.1 120/64 HR-72 20
Synthroid 100 mcg daily
HCTZ 12.5mg daily
Multivitamin daily
Aspirin 81 mg po daily, and simvastatin 40mg
Rating the pain as 5/10. Typically takes 1 to 2 tabs of OTC Naproxen with ‘some help’. “Sleeping it off in a darkened room’ helps alleviate the headache.

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Diagnostics/Assessments done:
1. CXR—no cardiopulmonary findings. WNL
2. CT head—diffuse Cerebral Atrophy
Treatments and prevention
The following are some common treatments based on the type of headache a person may have.
( some thoughts to consider below)
Tension
Tension headaches often cause mild to moderate pain. In some instances, over-the-counter (OTC) pain medication or rest will reduce pain. But if the pain is persistent or occurs frequently, a person may need additional treatment options.

Some prevention tips for tension headaches include:

eating regular meals and not skipping any
managing stress
getting regular rest
exercising each day for at least 30 minutes
avoiding triggers such as stress or lack of sleep
Learn about home remedies for headaches here.

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Cervicogenic
A person who has a cervicogenic headache should see their doctor for treatment. Since the headache is the result of an underlying condition in the neck, treatments focus on the neck.

Typical treatments for cervicogenic headaches can vary, but may include:

using nerve blocks
taking pain medication
having physical therapy
doing regular exercise
Migraine
Similar to tension headaches, treatment for migraines often involves improving the symptoms and preventing future migraines.

Some standard treatment options include:

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using medications, such as pain relievers, triptan or ergotamine drugs
resting in a dark, quiet room
drinking plenty of fluids
applying a cool damp cloth or ice pack on the forehead
undergoing hormone therapy
managing weight
writing down things that trigger the migraine headaches and try to avoid them
managing stress.

1. Basic Metabolic Panel as shown below
TEST RESULT REFERENCE RANGE
GLUCOSE 90 65–99
SODIUM 130 135–146
POTASSIUM 3.4 3.5–5.3
CHLORIDE 104 98–110
CARBON DIOXIDE 29 19–30
CALCIUM 9.0 8.6–10.3
BUN 15 7–25
CREATININE 70 0.70–1.25
GLOMERULAR FILTRATION RATE (eGFR) 60 >or=60 mL/min/1.73m2

__________________________________

Subjective

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72-year-old female patient with a history of hypertension, hyperlipidemia, and osteoporosis
Presents with a 1-week history of headache, tearing, and an itchy, burning sensation in both eyes
Headaches are described as throbbing, with a severity of 5/10
The patient denies nausea, vomiting, or visual disturbances
She has no history of migraine headaches
The patient is taking Synthroid 100 mcg daily, HCTZ 12.5 mg daily, a multivitamin, aspirin 81 mg daily, and simvastatin 40 mg

Objective

Vital signs: BP 120/64, HR 72, RR 20, Temp 98.1°F
General: Well-developed, well-nourished female in no acute distress
HEENT: Pupils equal, round, and reactive to light; sclerae anicteric; conjunctivae erythematous and edematous; no exudate or hemorrhage; visual acuity 20/50 OU
Neck: No jugular venous distension; no lymphadenopathy
Chest: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended; no hepatosplenomegaly
Extremities: No edema; no clubbing or cyanosis

Assessment

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Possible diagnoses:
Tension headache
Cervicogenic headache
Migraine headache
Sinusitis
Orbital cellulitis
Dry eye syndrome

Plan

Diagnostic studies:
CXR to rule out cardiopulmonary disease
CT head to rule out intracranial pathology
Ophthalmology consult to evaluate the eyes
Treatment:
Over-the-counter pain medication, such as ibuprofen or acetaminophen
Warm compresses or ice packs to the eyes
Artificial tears or lubricating ointment for the eyes
Referral to an ophthalmologist if the symptoms do not improve

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The patient should be educated about the different types of headaches and their causes.
She should be taught how to manage her headaches with over-the-counter pain medication and other non-pharmacologic therapies.
She should also be instructed to see her doctor if her headaches become more frequent or severe, or if they are accompanied by other symptoms, such as fever, nausea, vomiting, or visual disturbances.

Disposition

The patient will be discharged home with instructions to follow up with her doctor in 1 week if her symptoms do not improve.

Reflection

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This case was a challenge because the patient had a variety of symptoms that could have been caused by a number of different conditions. The key to making the diagnosis was to carefully gather the patient's history and perform a thorough physical examination. Once I had a better understanding of the patient's symptoms, I was able to order the appropriate diagnostic tests and make a diagnosis. I am confident that the patient will receive the treatment she needs to manage her headaches and improve her quality of life.

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