Posted: October 6th, 2022

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

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

Head, neck, and face problems are widespread, and thus you’ll seemingly take care of aged sufferers with these problems. In your position as a complicated observe nurse, you have to be ready not solely to accurately assess and diagnose sufferers but additionally Help sufferers handle the dysfunction by planning essential therapies, assessments, and follow-up care.

To arrange:

Evaluate the case examine offered by your Teacher.
Mirror on the affected person’s signs and features of problems which may be current.
Contemplate the way you would possibly assess, carry out diagnostic exams, and advocate medicines to deal with sufferers presenting with the signs within the case.
Entry the Targeted SOAP Word Template on this week’s Assets.
The Task:

Full the Targeted SOAP Word Template offered for the affected person within the case examine. You should definitely tackle the next:

Subjective: What was the affected person’s subjective criticism? What particulars did the affected person present relating to their historical past of current sickness and private and medical historical past? Embody an inventory of prescription and over-the-counter medicine the affected person is at present taking. Examine this record to the American Geriatrics Society Beers Standards®, and think about various medicine if applicable. Present a overview of programs.
Goal: What observations did you observe from the bodily Assessment? What have been the lab, imaging, or useful assessments outcomes?
Assessment: Present a minimal of three differential diagnoses. Record them from prime precedence to least precedence. Examine the diagnostic standards for every, and clarify what guidelines every differential in or out. Clarify you vital considering course of that led you to the first prognosis you chose. Embody pertinent positives and pertinent negatives for the particular affected person case.
Plan: Present an in depth remedy plan for the affected person that addresses every prognosis, as relevant. Embody documentation of diagnostic research that will probably be obtained, referrals to different health-care suppliers, therapeutic interventions, training, disposition of the affected person, caregiver help, and any deliberate follow-up visits. Present a dialogue of well being promotion and illness prevention for the affected person, considering affected person components, previous medical historical past (PMH), and different danger components. Lastly, embrace a mirrored image assertion on the case that describes insights or classes realized.
Present no less than three evidence-based peer-reviewed journal articles or evidenced-based tips, which relate to this case to help your diagnostics and differentials diagnoses. Ensure they’re present (not more than 5 years previous) and help the remedy plan in following present requirements of care. Observe APA seventh version
Case examine
72 12 months previous Dickson a feminine affected person seen in Workplace with clear speech and historical past of headache, denies nausea. She denies any visible or auditory hallucinations. tearing and an itchy, burning sensation in each eyes. Complications have develop into extra debilitating just lately. some neck ache. The affected person states this isn’t a brand new downside, however it has worsened up to now week and is affecting her imaginative and prescient. The affected person complains that her eyes are dry. Her visible acuity is 20/50 OU, 20/40 OD, 20/50 OS. The eyelids are erythematous and edematous with yellow crusting across the lashes She denies any suicidal ideas or ideations. She is alert and oriented to individual, partially oriented to position however is disoriented to time and place. Evaluate of System and Bodily Examination findings are adverse aside from said.
PMH: Hypertension, Hyperlipidemia, Osteoporosis
Important Indicators: 98.1 120/64 HR-72 20
Synthroid 100 mcg each day
HCTZ 12.5mg each day
Multivitamin each day
Aspirin 81 mg po each day, and simvastatin 40mg
Ranking the ache as 5/10. Usually takes 1 to 2 tabs of OTC Naproxen with ‘some Help’. “Sleeping it off in a darkened room’ helps alleviate the headache.

Diagnostics/Assessments carried out:
1. CXR—no cardiopulmonary findings. WNL
2. CT head—diffuse Cerebral Atrophy
Therapies and prevention
The next are some widespread therapies primarily based on the kind of headache an individual could have.
( some ideas to think about under)
Stress
Stress complications usually trigger gentle to reasonable ache. In some situations, over-the-counter (OTC) ache treatment or relaxation will cut back ache. But when the ache is persistent or happens continuously, an individual might have further remedy choices.

Some prevention ideas for pressure complications embrace:

consuming common meals and not skipping any
managing stress
getting common relaxation
exercising every day for no less than 30 minutes
avoiding triggers akin to stress or lack of sleep
Find out about dwelling cures for complications right here.

Cervicogenic
An individual who has a cervicogenic headache ought to see their physician for remedy. For the reason that headache is the results of an underlying situation within the neck, therapies concentrate on the neck.

Typical therapies for cervicogenic complications can range, however could embrace:

utilizing nerve blocks
taking ache treatment
having bodily remedy
doing common train
Migraine
Just like pressure complications, remedy for migraines usually includes enhancing the signs and stopping future migraines.

Some customary remedy choices embrace:

utilizing medicines, akin to ache relievers, triptan or ergotamine medicine
resting in a darkish, quiet room
ingesting loads of fluids
making use of a cool damp material or ice pack on the brow
present process hormone remedy
managing weight
writing down issues that set off the migraine complications and attempt to keep away from them
managing stress.

1. Primary Metabolic Panel as proven under
TEST RESULT REFERENCE RANGE
GLUCOSE 90 65–99
SODIUM 130 135–146
POTASSIUM three.four three.5–5.three
CHLORIDE 104 98–110
CARBON DIOXIDE 29 19–30
CALCIUM 9.zero eight.6–10.three
BUN 15 7–25
CREATININE 70 zero.70–1.25
GLOMERULAR FILTRATION RATE (eGFR) 60 >or=60 mL/min/1.73m2
—

Targeted SOAP Word

Pupil’s Identify
Institutional Affiliation
Course
Professor’s Identify
Date

Targeted SOAP Word
Affected person Data:
D, 72-years previous feminine.
S.
Chief Criticism (CC):
Debilitating headache and neck ache
HPI:
Dickson is a 72-year previous feminine who involves the clinic with a debilitating headache and neck ache. The affected person complains that the issue isn’t new, however has worsened within the final week and at present it’s affecting her imaginative and prescient. She denies of any visible or auditory hallucinations. The affected person complains of dry eyes and imaginative and prescient issues. Usually takes 1 to 2 tabs of OTC Naproxen with ‘some Help’. “Sleeping it off in a darkened room’ helps alleviate the headache. Ranking the ache as 5/10.
Present Drugs:
The present treatment embrace Synthroid 100 mcg each day, HCTZ 12.5mg each day, Multivitamin each day, Aspirin 81 mg PO each day, and simvastatin 40mg.
Allergic reactions:
NKDA
PMHx:
Hypertension, Hyperlipidemia, Osteoporosis
PSHx:
No info is out there
Soc Hx:
No info is out there.
Fam Hx:
No info is out there.
ROS:
GENERAL:
The affected person complains that her eyes are dry. Her visible acuity is 20/50 OU, 20/40 OD, 20/50 OS. The eyelids are erythematous and edematous with yellow crusting across the lashes.
HEENT:
Eyes: eyes are dry. Her visible acuity is 20/50 OU, 20/40 OD, 20/50 OS. She denies tearing and an itchy, burning sensation in each eyes. The eyelids are erythematous and edematous with yellow crusting across the lashes
Ears: No info is out there.
Nostril: No info is out there.
Throat: No info is out there.
SKIN:
No pores and skin situation reported up to now.
CARDIOVASCULAR:
No chest ache, edema, or uncontrolled coronary heart situations. Recognized with hypertension and Hyperlipidemia however they’re well-controlled utilizing medicine.
RESPIRATORY:
No respiratory situation like nasal congestion is famous.
GASTROINTESTINAL:
No complaints of irregular bowel motion, no nausea, vomiting or blood within the stool. GENITOURINARY:
The affected person doesn’t complain of dysuria or polyuria or ache whereas passing urine.
NEUROLOGICAL:
No irregular bowel and bladder management is famous. Debilitating headache. No dizziness or seizures.
MUSCULOSKELETAL:
No abnormalities famous or again ache.
HEMATOLOGIC:
The affected person has no blood dysfunction or extreme bleeding.
LYMPHATICS:
No historical past of swollen lymph nodes.
PSYCHIATRIC:
No historical past of despair or stress. Affected person denies suicidal ideas or ideations.
ENDOCRINOLOGIC:
No irregular sweating, extreme thirst or fever at evening.
ALLERGIES:
NKDA
O.
V.S:
98.1 120/64 HR-72 20
Bodily examination:
A bodily examination reveals that the eyelids are erythematous and edematous with yellow crusting across the lashes. Her visible acuity is 20/50 OU, 20/40 OD, 20/50 OS.
HEENT, CV, Respiratory, Musculoskeletal, Lymphatic, Allergic reactions, and Diagnostic outcomes:
The knowledge from subjective and goal knowledge reveals the affected person is unwell because of the debilitating headache.
Head: Regular head and neck motion. No bruises or swelling.
Ears: No erythema.
Eyes: Imaginative and prescient issues on account of headache.
Nostril: No nasal congestion or rhinorrhea.
Throat: No erythema or swelling and clear speech.
Neck: No swelling or palpable lymph.
Cardiovascular: Hypertensive.
Respiratory: Clear lungs and no adventitious sound.
Neurological: She is alert and oriented to individual, partially oriented to position however is disoriented to time and place.
Diagnostic Outcomes:
CXR—no cardiopulmonary findings. WNL 2.
CT head—diffuse Cerebral Atrophy
A.
Differential Diagnoses:
a) Cervicogenic:
Cervicogenic is a headache that develops within the neck, though an individual feels ache within the neck. It is likely one of the secondary complications attributable to underlying situations. A number of the underlying situations embrace extreme hypertension, neck accidents, and infections (Reiley et al., 2017). Others have broken disc or motion that compresses the nerves across the neck. A number of the situations’ therapies embrace energetic way of life, treatment, doable surgical procedure, and reducing the blood stress (Reiley et al., 2017). The situation signs embrace ache across the eyes, a stiff neck, ache on one aspect of the neck, and headache with particular neck postures. The situation is continual and could proceed for months or years (Barmherzig & Kingston, 2019). Prognosis of the situation includes guide examination methods, diagnostic nerve blocks, and medical historical past analysis.
Cervicogenic is the doable situation the affected person is affected by because of the similarities within the signs.
b) Stress Headache:
Stress headache triggers diffuse, gentle to reasonable ache. The situation seems like a good band across the head. The causes of the illness should not well-understood. It happens at any age, and it is likely one of the commonest varieties of headache (Eidlitz-Markus et al., 2017). A number of the causes embrace poor posture, insufficient sleep, and stress. It causes ache on either side of the pinnacle. Some accessible therapies embrace ache relievers, stress discount, and sleeping on good posture (Eidlitz-Markus et al., 2017). It causes uninteresting itching head ache, a sensation of tightness on the brow, tenderness on the scalp, or shoulder muscular tissues. s
Migraine headache
Migraine headache causes extreme throbbing ache, normally on the aspect of the pinnacle. It’s accompanied by vomiting, nausea, and excessive sensitivity to gentle (Mayans & Walling, 2018). The migraine assaults can final for hours or days. The ache could be so extreme that it interferes with each day actions. The causes embrace emotional triggers akin to stress, despair, anxiousness, and pleasure (Mayans & Walling, 2018). Hormonal adjustments can even set off the situation, particularly throughout menstruation. Dietary components embrace consuming sure varieties of meals, alcohol, and caffeine. Menstrual adjustments are widespread amongst ladies, particularly throughout being pregnant and menopause (Mayans & Walling, 2018). Taking contraceptives can worsen the situation. Sufferers take ache relievers, triptans, anti-nausea medicine, and opioid treatment.
Therapy Plan
Therapy for Cervicogenic includes concentrating on the reason for the ache within the neck. It varies relying on what works greatest for particular person sufferers. A number of the greatest therapies embrace bodily remedy and train, treatment, and nerve blocks (Jafari et al., 2017). Proof-based observe reveals steady train routine will generate high quality outcomes. Handbook remedy of the situation includes therapeutic massage, manipulation, and bodily remedy. Therapy focuses on relieving ache or stress on the joints (Jafari et al., 2017). The affected person also needs to take treatment akin to tricyclic antidepressants and anti-epileptic medicine.
The affected person ought to train each day whereas going for remedy 3 times every week. She ought to take treatment each day to alleviate the ache. It’s important to sleep in a very good posture, keep away from stress or hypertension (Jafari et al., 2017). The affected person ought to take the treatment for hypertension persistently to stop issues. She ought to eat a balanced eating regimen. It’s essential to keep away from stressing actions akin to lifting heavy objects.
Affected person training includes avoiding actions that may set off ache or stress on the neck or head. The affected person ought to seek the advice of with a doctor to evaluate if the blood stress is stabilizing or worsening. She ought to proceed taking treatment for all of the well being situations.
The remedy plan ought to contain referral to a psychiatrist or counselor to additional consider the affected person’s psychological situation. Proof-based observe reveals that despair and stress can spike blood stress, triggering complications (Reiley et al., 2017). If the affected person had a psychological situation akin to stress, they need to see the counselor for a number of periods till their psychological well being improves drastically.
Reflection
The Assessment of the affected person’s well being situation reveals that additional info is required for a greater analysis. A medical historical past needs to be detailed to ascertain if some situations may very well be inflicting ache. The affected person ought to proceed taking the treatment and come again for an Assessment to find out if the state of affairs is enhancing, stabilizing, or worsening.
I realized varied classes through the Assessment. One of many classes is that underlying situations can set off ache within the head. As an illustration, extreme blood stress may cause a headache. The physicians’ accountability is to make sure they consider the underlying situations to find out the true causes of ache. I additionally realized that complications may happen on account of totally different causes. Thus, the affected person wants to come back for remedy continuously after the primary Assessment to judge the progress. Some complications can sign a extreme situation that may result in dying or rapture of the blood vessels.
Affected person training is crucial for the remedy of situations akin to complications. It is likely one of the approaches that change the life-style that may set off a headache. As an illustration, poor sleeping postures, avoiding stress, and maintaining a healthy diet can rework a affected person’s well being. I additionally realized that it’s the accountability of sufferers to offer enough details about their well being situation. The knowledge is essential in analyzing the situation a affected person could also be affected by.

References
Barmherzig, R., & Kingston, W. (2019). Occipital neuralgia and cervicogenic headache: prognosis and administration. Present Neurology and Neuroscience Reviews, 19(5), 20.
Eidlitz-Markus, T., Zolden, S., Haimi-Cohen, Y., & Zeharia, A. (2017). Comparability of comorbidities of migraine and pressure headache in a pediatric headache clinic. Cephalalgia, 37(12), 1135-1144.
Jafari, M., Bahrpeyma, F., & Togha, M. (2017). Impact of ischemic compression for cervicogenic headache and elastic conduct of energetic set off level within the sternocleidomastoid muscle utilizing ultrasound imaging. Journal of Bodywork and Motion Therapies, 21(four), 933-939.
Mayans, L., & Walling, A. (2018). Acute migraine headache: remedy methods. American Household Doctor, 97(four), 243-251.
Reiley, A. S., Vickory, F. M., Funderburg, S. E., Cesario, R. A., & Clendaniel, R. A. (2017). diagnose cervicogenic dizziness. Archives of Physiotherapy, 7(1), 12.

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