Posted: October 31st, 2023

Case Study Assignment: Evaluating Neurological Symptoms

References
Akhondi, H., Woldemariam, B., & Rajasurya, V. (2022). Fungal sinusitis. In StatPearls
[Internet]. StatPearls Publishing.
Bousquet, J., Anto, J. M., Bachert, C., Baiardini, I., Bosnic-Anticevich, S., Walter Canonica, G.,
… & Toppila-Salmi, S. (2020). Allergic rhinitis. Nature Reviews Disease Primers, 6(1),
95.
Liva, G. A., Karatzanis, A. D., & Prokopakis, E. P. (2021). Review of rhinitis: classification,
types, pathophysiology. Journal of clinical medicine, 10(14), 3183.
Sedaghat, A. R., Kuan, E. C., & Scadding, G. K. (2022). Epidemiology of chronic rhinosinusitis:
prevalence and risk factors. The Journal of Allergy and Clinical Immunology: In
Practice, 10(6), 1395-1403.
Wyler, B., & Mallon, W. K. (2019). Sinusitis update. Emergency Medicine Clinics, 37(1), 41-54.
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Case Study Assignment: Evaluating Neurological Symptoms

Student Name: [Your Name]
Institution: [Your Institution Name]
Professor: [Professor’s Name]
Submission Date: [Submission Date]

Patient Information:

Initials: H.K.
Sex: Female
Age: 40 years
Race: European American
Chief Complaint (CC): “I have been experiencing a headache.”
History of Present Illness (HPI):
H.K., a 40-year-old European American woman, presented at the clinic with a headache that has persisted for a week. She described the headache as a pressure sensation behind her eyes, primarily across her forehead. The pain is exacerbated when she bends forward and relieved by acetaminophen. She reported the headache’s severity as 8/10 at its worst, 4/10 after taking acetaminophen, and currently 2/10. H.K. mentioned experiencing a “head cold” three weeks ago, which seemed to improve, but her sinus symptoms have returned and worsened. She cannot breathe through her nose due to pressure behind her eyes and has a history of postnasal drip. She has found relief with Sudafed HCL, though the symptoms are more pronounced in the morning. She also noted awakening with a headache, experiencing occasional feverish sensations, a loss of appetite, frequent sneezing, concentration difficulties at work, and persistent fatigue.

Medications:

Oral Acetaminophen 500 mg as needed
Oral Sudafed HCL 120 mg every 12 hours
Allergies: No known allergies

Past Medical History (PMHx):
H.K. had a history of open reduction internal fixation (ORIF) for a clavicle fracture. She reported that her immunization history is up to date.

Social and Substance History:
H.K. is a police officer working with the Maryland police department, and her hobbies include baking and knitting. She is married and lives with her husband and two children. She adheres to safety protocols while driving, including using a seatbelt. H.K. consumes a daily glass of wine and occasionally smokes shisha with friends but denies using recreational drugs.

Family History:

Mother: Deceased with congestive heart failure and hypertension.
Father: Alive with asthma, diabetes, and testicular cancer.
Maternal grandparents: Deceased in an accident.
Paternal grandfather: Deceased due to cardiac arrest.
Paternal grandmother: Alive with asthma, diabetes, and hypertension.
Review of Systems (ROS):

General: Fatigue, fever, and appetite loss with no chills or temperature sensitivity.
HEENT (Head, Eyes, Ears, Nose, Throat): Headaches but no lightheadedness or head trauma. No excessive tearing, scleral yellowness, visual disturbances, or eye discharges. Postnasal drip, sneezing, and nasal congestion with no anosmia or epistaxis. No raspy voice, swallowing problems, or dental issues.
Skin: No rashes, itchiness, or color changes.
Cardiovascular: No shortness of breath, palpitations, chest pain, or edema.
Respiratory: Nonproductive cough, chest pain, difficulty breathing, or fast breathing.
Gastrointestinal: Previous appetite loss with no nausea, vomiting, or diarrhea.
Neurological: Headaches but no numbness, memory loss, seizures, tingling, or syncope.
Musculoskeletal: No back pain, joint stiffness, muscle weakness, or joint pain.
Hematologic: No blood transfusions, easy bleeding, or bruising.
Lymphatics: No appendectomy or enlarged nodes.
Objective Findings (O):

Vital Signs:

BP: 134/87
PR: 91
RR: 19
Temp: 97.3
O2 saturation: 98% on room air
Weight: 146 lbs
Height: 5’8″
BMI: 22.2 (Healthy)
General Assessment:
H.K. is a middle-aged woman with adequate nutrition, well-dressed, cooperative, oriented to time, place, and person.

Skin:
Normal skin without rashes, warm, well-perfused, and normal skin turgor.

HEENT:

Head: No trauma, even hair distribution, no scars or swelling.
Eyes: Clear conjunctiva and sclera, normal extraocular motions, PERRLA, and normal visual acuity.
Ears: Transparent tympanic membranes, normal external ear, successful whisper test.
Nose: Normal shape, non-deviated septum, patent nares, erythematous and edematous nasal mucosa, nasal discharge, tenderness on frontal and ethmoidal sinus palpation.
Throat: Moist and intact mucous membranes, normal tonsils, and dentation.
Cardiovascular:
No jugular vein engorgement, chest abnormalities, or lower limb edema. No chest tenderness, palpable peripheral pulses, normal rate, and rhythm of S1 and S2.

Respiratory:
Even chest expansion without scars, abnormalities, or use of accessory muscles. Resonant lungs and even chest expansion on palpation. Audible and distinct breath sounds on auscultation.

Gastrointestinal:
Abdominal movement with breathing, no scars, bowel sounds in all quadrants, tympanic abdomen upon percussion, and no tenderness, organomegaly upon deep or superficial palpation.

Neurological:
Normal cranial nerves and senses. H.K. is attentive, cooperative, with normal muscular tone and power, regular speech volume and tone, good short- and long-term memory, normal reflexes, and senses.

Musculoskeletal:
No visible defects, normal gait, no missing digits or limbs, and no inflamed joints. Normal range of motion and no joint stiffness or tenderness on palpation.

Diagnostic Studies:

Allergy skin test
Total serum IgE
Assessment (A):
Based on the patient’s history and examination, several differential diagnoses can be considered:

Allergic Rhinitis: Characterized by symptoms of postnasal drip, nasal pruritus, nasal congestion, and clear rhinorrhea. Seasonal or intermittent allergic rhinitis presents with sneezing, watery eyes, and a runny nose, while chronic allergic rhinitis exhibits postnasal drip, ongoing congestion, and obstruction (Bousquet et al., 2020).

Acute Sinusitis: Often occurs due to viral infections, causing symptoms like nasal congestion, headaches, mucus discharge, pressure in the ears, and fever. Patients may experience frontal sinus pressure and neck discomfort (Wyler & Mallon, 2019).

Fungal Sinusitis: A condition where fungal infection contributes to nasal and sinus inflammation, resulting in a foul odor, diminished sense of smell, fever, nasal and sinus edema, congestion, pain, tenderness, and sinus headaches (Akhondi et al., 2022).

Infectious Rhinitis (Viral Rhinitis): A viral infection in the nose and throat causes inflammation, leading to postnasal drip, facial or dental pain, cough, nasal congestion, and purulent rhinorrhea (Liva et al., 2021).

Chronic Rhinitis: This condition is characterized by persistent nasal obstruction or discharge due to ongoing irritation or inflammation within the nasal passages. Symptoms include a runny nose, postnasal drip, mouth breathing, sinus pressure, infections, throat soreness, and a persistent cough (Sedaghat et al., 2022).