Assessing Neurological System

ASSESSING NEUROLOGICAL SYSTEM 5

AssessingNeurological System

Assessingneurological system

Case3: Drooping of Face

A33-year-old female is alarmed about a sudden drooping on the rightside of the face that began in the morning. She complains ofexcessive tearing and drooling on her right side as well.

SubjectiveData

Patientdetails: age: 33. Gender: Female

Historyof present illness: day old medical illness. The patient comes toclinic today complaining that she had sudden drooping on the rightside of her face. She also complained of excessive tearing on herright side as well.

Thepatient past medical, surgical, immunization or allergy history wouldbe necessary to collect from the patient.

Reviewof systems

Heent:a check to see if the patient is complaining of the following the offacial pain, drooling, tearing off the eye, muscle twitching earachesespecially on the right side of her face.

Doesthe patient have any problem with her respiratory, cardiovascular,gastrointestinal, integumentary, musculoskeletal and psychiatric(Dains, et al. 2012).

Neurological:is she complaining of a headache.

ObjectiveData

Generalphysical examination of the patient: how does she appear to bewell-nourished, alert, cooperative, oriented?

Thefollowing ought to be tested: facial muscles whereby the patientshould be asked to lift her right side eyebrow, close the right eye,and try smiling (Carpenito-Moyet, 2007).

Anelectromyography should be conducted which is intended to check themuscles health and the nerves responsible for controlling them(LeBlond,et al. 2009). Imaging scans are to be used to analyze thecause for the drooling face. Blood test too is conducted.

Assessment

Suddendrooping on the right side of the face there are five conditionslinked to the drooping of one side of the face:

RamsayHunt Syndrome: this causes reduced sensation on the patient rightside part of the face.

Bell’spalsy: this causes paralysis or weakness in some facial muscles.

Stroke:this occurs when oxygen carried by blood are both cut off thuscausing confusion numbness among others.

Ministroke (Transient ischemic attack) this causes numbness, weakness inthe face and headache.

Lymedisease: symptoms include chills, rash, and fever. It is caused bybacteria infection.

Plan

Conducta complete physical exam and if worried about a bigger problem plan aCT scan of the head.

References

Carpenito-Moyet,L. J. (2007). Nursingdiagnosis: Application to clinical practice.Philadelphia, Pa: Lippincott Williams &amp Wilkins.

Dains,J., Baumann, L. Scheibel, P. (2012). Advanced health assessment andclinical diagnosis in primary care (4th ed.). St. Louis, MO: ElsevierMosby.

LeBlond,R. F., DeGowin, R. L., &amp Brown, D. D. (2009). DeGowin`sdiagnostic examination.New York: McGraw-Hill Medical.