Assessing, Diagnosing, and Treating Head, Neck, and Face Disorders<\/p>\n
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.<\/p>\n
To prepare:<\/p>\n
Review the case study provided by your Instructor.
\nReflect on the patient\u2019s symptoms and aspects of disorders that may be present.
\nConsider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
\nAccess the Focused SOAP Note Template in this week\u2019s Resources.
\nThe Assignment:<\/p>\n
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:<\/p>\n
Subjective: What was the patient\u2019s 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\u00ae, and consider alternative drugs if appropriate. Provide a review of systems.
\nObjective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
\nAssessment: 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.
\nPlan: 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.
\nProvide 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
\nCase study
\n72 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.
\nPMH: Hypertension, Hyperlipidemia, Osteoporosis
\nVital Signs: 98.1 120\/64 HR-72 20
\nSynthroid 100 mcg daily
\nHCTZ 12.5mg daily
\nMultivitamin daily
\nAspirin 81 mg po daily, and simvastatin 40mg
\nRating the pain as 5\/10. Typically takes 1 to 2 tabs of OTC Naproxen with \u2018some help\u2019. \u201cSleeping it off in a darkened room\u2019 helps alleviate the headache.<\/p>\n
Diagnostics\/Assessments done:
\n1. CXR\u2014no cardiopulmonary findings. WNL
\n2. CT head\u2014diffuse Cerebral Atrophy
\nTreatments and prevention
\nThe following are some common treatments based on the type of headache a person may have.
\n( some thoughts to consider below)
\nTension
\nTension 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.<\/p>\n
Some prevention tips for tension headaches include:<\/p>\n
eating regular meals and not skipping any
\nmanaging stress
\ngetting regular rest
\nexercising each day for at least 30 minutes
\navoiding triggers such as stress or lack of sleep
\nLearn about home remedies for headaches here.<\/p>\n
Cervicogenic
\nA 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.<\/p>\n
Typical treatments for cervicogenic headaches can vary, but may include:<\/p>\n
using nerve blocks
\ntaking pain medication
\nhaving physical therapy
\ndoing regular exercise
\nMigraine
\nSimilar to tension headaches, treatment for migraines often involves improving the symptoms and preventing future migraines.<\/p>\n
Some standard treatment options include:<\/p>\n
using medications, such as pain relievers, triptan or ergotamine drugs
\nresting in a dark, quiet room
\ndrinking plenty of fluids
\napplying a cool damp cloth or ice pack on the forehead
\nundergoing hormone therapy
\nmanaging weight
\nwriting down things that trigger the migraine headaches and try to avoid them
\nmanaging stress.<\/p>\n
1. Basic Metabolic Panel as shown below
\nTEST RESULT REFERENCE RANGE
\nGLUCOSE 90 65\u201399
\nSODIUM 130 135\u2013146
\nPOTASSIUM 3.4 3.5\u20135.3
\nCHLORIDE 104 98\u2013110
\nCARBON DIOXIDE 29 19\u201330
\nCALCIUM 9.0 8.6\u201310.3
\nBUN 15 7\u201325
\nCREATININE 70 0.70\u20131.25
\nGLOMERULAR FILTRATION RATE (eGFR) 60 >or=60 mL\/min\/1.73m2<\/p>\n
__________________________________<\/p>\n
Subjective<\/p>\n
72-year-old female patient with a history of hypertension, hyperlipidemia, and osteoporosis
\nPresents with a 1-week history of headache, tearing, and an itchy, burning sensation in both eyes
\nHeadaches are described as throbbing, with a severity of 5\/10
\nThe patient denies nausea, vomiting, or visual disturbances
\nShe has no history of migraine headaches
\nThe patient is taking Synthroid 100 mcg daily, HCTZ 12.5 mg daily, a multivitamin, aspirin 81 mg daily, and simvastatin 40 mg<\/p>\n
Objective<\/p>\n
Vital signs: BP 120\/64, HR 72, RR 20, Temp 98.1\u00b0F
\nGeneral: Well-developed, well-nourished female in no acute distress
\nHEENT: Pupils equal, round, and reactive to light; sclerae anicteric; conjunctivae erythematous and edematous; no exudate or hemorrhage; visual acuity 20\/50 OU
\nNeck: No jugular venous distension; no lymphadenopathy
\nChest: Clear to auscultation bilaterally
\nAbdomen: Soft, non-tender, non-distended; no hepatosplenomegaly
\nExtremities: No edema; no clubbing or cyanosis<\/p>\n
Assessment<\/p>\n
Possible diagnoses:
\nTension headache
\nCervicogenic headache
\nMigraine headache
\nSinusitis
\nOrbital cellulitis
\nDry eye syndrome<\/p>\n
Plan<\/p>\n
Diagnostic studies:
\nCXR to rule out cardiopulmonary disease
\nCT head to rule out intracranial pathology
\nOphthalmology consult to evaluate the eyes
\nTreatment:
\nOver-the-counter pain medication, such as ibuprofen or acetaminophen
\nWarm compresses or ice packs to the eyes
\nArtificial tears or lubricating ointment for the eyes
\nReferral to an ophthalmologist if the symptoms do not improve<\/p>\n
Education<\/p>\n
The patient should be educated about the different types of headaches and their causes.
\nShe should be taught how to manage her headaches with over-the-counter pain medication and other non-pharmacologic therapies.
\nShe 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.<\/p>\n
Disposition<\/p>\n
The patient will be discharged home with instructions to follow up with her doctor in 1 week if her symptoms do not improve.<\/p>\n
Reflection<\/p>\n
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.<\/p>\n","protected":false},"excerpt":{"rendered":"
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