NURS 6512 CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS
Patient initial:S.M Age: 48 years old Gender: Male
CC: Bilateral Foot Pain
HPI
S.M is a 48-year-old Hispanic male present to the facility with complaints of discomfort in her toes and the left foot, as well as heel of the right foot tingling and numbness over the previous two weeks. He is worried about his life since the pain forces him to drop his work equipment. The patient states that he is unable to bear weight. In the right wrist, the pain is assessed at a 37 out of 10. When he engages in physical activity, the pain is intensified. Nevertheless, relaxing and using medications including Ibuprofen 800mg PO as required and Tylenol 325mg PO as appropriate will help to alleviate the pain.
Current Medications for NURS 6512 CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS Patient
Ibuprofen 800mg PO as required for pain
Multivitamin PO daily
Tylenol 500mg PO as needed for pain
Allergies
No known drug or environmental allergies
PMH
Type 2 Diabetes Mellitus
PSH
No surgical history
Sexual/Reproductive History: Heterosexual; sexually active
Personal/Social History: Married, denies cigarette smoking, alcohol, and illicit drug use
Immunization History: Patient’s immunizations up to date; Influenza vaccine 2020; Last Tdap 11/2017
Significant Family History:
Mother: History of obesity
Father: History of diabetes
Paternal grandmother: died age 80 due to hypertension
Paternal grandfather died age 86 from cardiac arrest; history of dementia
Maternal grandmother died age 75 from heart attack; history of breast cancer
Maternal grandfather died age 72 from throat cancer
Lifestyle: S.M lives at home with his 40 years old wife. He works 9 hours a day at a workshop. He has a primary care physician and goes for his monthly checkups. He denies mental health problems. He denies exposure to domestic violence.
Review of Systems:
General: Denies experiencing headaches, migraines or insomnia
HEENT: Head: Atraumatic and Normocephalic,. Eyes: no double vision or vision loss. ENT: the oral mucosa seems moist; Denies hearing loss or problems
Neck: No pain or discomfort; Trachea midline Breasts:
Respiratory: No history of SOB, or past TB illnesses.
Cardiovascular/Peripheral Vascular: ; No chest pain or discomfort; Denies heart palpitation
Gastrointestinal: No appetite loss or changes or weight gain. Denies vomiting, nausea, diarrhea, or constipation
Genitourinary: Denies incontinence or frequency on urination.
Musculoskeletal: pain in her toes and left foot, with tingling and numbness in the heel of the right foot
Neurological: Denies history of seizures.
Skin: Intact, warm and dry. Denies open wounds or rashes.
Objective Data
Vital signs: Temp 97.9 oral; BP 122/45 MAP 70 Right arm sitting; HR 77; RR 16 non-labored; O2 99% room air; Wt.: 60kg; Ht: 5’5”; BMI: 26.4
General: Patient alert and oriented x4 with no acute distress. He is a well-nourished and developed man who appears his stated age.
HEENT: Pupils respond equally to light. He is not jaundiced or pale. Moist Oral mucosa. No pharyngeal erythema.
Neck: There is no neck elevation. No carotid swelling, or bruit.
Chest/Lungs: is adequate bilateral air entry. Bilaterally clear lung sounds. No coughing or wheezing.
Heart/Peripheral Vascular: Ha uniform rhythm and rate . No gallop, murmur, rub. Regular peripheral circulation
Abdomen: stomach is soft and nontender. Bowel sounds present and regular. Recent known bowel movement 1 days ago
Genital/Rectal: Deffered
Musculoskeletal: Has full ROM. No found swelling or deformities. Right foot strength 3/5 and Left toe abduction 2/5
Neurological: Alert and oriented with no acute distress; Has a steady gait. Congruent mood and affect.
Diagnostic results:
X-ray Upper extremity: X-rays of the feet may be ordered if there is limited toe motion, or evidence of arthritis or trauma. (Cleveland Clinic, 2021)
Tinel’s Sign: tap or press on the median nerve in your feet with a reflex hammer. If your toes tingle or if you feel an electric-shock-like sensation, the test is positive (Cleveland Clinic, 2021).
Phalen test: rests his feet on a table and allows the heel to fall forward freely. If numbness and tingling is experience in the toes within 60 seconds, the test is positive (Cleveland Clinic, 2021).
Differential Diagnoses
Tarsal Tunnel Syndrome: Tarsal tunnel syndrome is a more probable differential diagnosis, and it happens when the tibial nerve, which runs posterior to the medial side, gets entrapped, causing symptoms such as searing pain or tingling in the sole of the foot or the lower heel (Rose & Singh, 2020). A positive Tinel’s test is common in individuals with tarsal tunnel syndrome, (Rose & Singh, 2020).
Multiple Sclerosis: Numbness is a feeling that is absent, reduced, or altered. One may get a pins and needles feeling along with the sense of your leg being “asleep” (NMSS, 2020). Despite the patient’s complaints of tingling and numbing, no indication of changed sensation was made.
Paget’s Disease: Paget’s disease is a condition in which bone metabolism is accelerated as a consequence of aberrant and excessive bone resorption and creation (McCance & Huether, 2014). This is a more significant diagnosis to evaluate, because it impacts the axial skeleton, “particularly the vertebrae, head, sacrum, sternum, pelvic, and femur. The symptoms correspond to the issues displayed by the patient.
Peripheral Neuropathy: Peripheral neuropathy is a sort of nerve injury that damages the legs and feet, as well as the hands and arms on occasion. Burning, tingling, or “pins and needles” sensations, numbness, discomfort, and weakness are some of the symptoms (NIDDK, 2018). The symptoms correspond to the complaints expressed by the patient.
Foot Sprain: A foot sprain is a frequent ailment, especially in the workplace and in sports. A ligament damage caused by an acute traumatic incident or chronic repeated motions is known as an acute foot sprain (May & Varacallo, 2020). As a manual worker, the patient’s legs are repeatedly moved, potentially spraining her feet.
