NURS 680B 28-year old female presents with severe headache
NURS 680B 28-year old female presents with severe headache
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, choice #2 19-year old male.
A 28-year old female presents with a “severe headache” for the past 9 hours. She states the pain is over the left temporal area and is “throbbing” in nature. These symptoms have occurred before but not as bad.
A 54-year old woman complain of left side drooling and facial drooping since earlier this morning.
A 64-year old diabetic man reports he has numbness and burning sensations in his toes for the past 6 months.
For the case you have chosen, post to the discussion:
Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
In SOAP format, list:
Pertinent positive and negative information
Differential and working diagnosis
Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
In your peer replies, please reply to at least one peer who chose a different case study.
You’re responding to a 54-year-old woman with facial weakness. The patient states she looked in the mirror this morning and noticed her face appeared “twisted.” She didn’t notice any facial asymmetry before going to bed the night before. She complains of no pain or numbness.
Your assessment shows the right side of her mouth isn’t able to smile and she has difficulty closing her right eye. You perform a neurologic exam; strength and sensation are normal throughout, with no weakness in the arms or legs and no other neurologic findings. She’s able to communicate and answers all questions appropriately. Is this a stroke?
Facial Weakness
The two most common causes of acute facial paralysis are Bell’s palsy and ischemic stroke.1 EMS providers are often faced with the challenge of differentiating between these two diagnoses. Because acute stroke is a time-critical illness, the distinction between stroke and Bell’s palsy must be made quickly to avoid unnecessary delays in treatment.
Two facial nerves, the right and the left, control all of the muscles in the face. The right facial nerve controls all of the muscles on the right side and the left facial nerve controls all of the muscles on the left side of the face. The facial nerves emerge from the middle of the brainstem (the pons) and carry motor fibers to the muscles of facial expression. These fibers come from the motor cortex of both cerebral hemispheres. From their origin in the motor strip of the cortex, they can be split into additional fibers that supply muscles in the upper face, including those controlling eye closure and forehead movement, and fibers that supply muscles in the lower face, including the mouth.
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The fibers that control the lower face travel from the cortex down to the brainstem. In the brainstem, these fibers cross over to the opposite, or contralateral, facial nerve.
The fibers that control the upper face take a slightly different path. After travelling down to the brainstem, half of the fibers cross over to the contralateral facial nerve, and half remain on the same side and contribute to the ipsilateral facial nerve.
Therefore, the eyes and forehead receive innervation from both hemispheres, while the lower face only receives innervation from the contralateral hemisphere.2
Why does this matter? The strictly contralateral innervation of the lower half of the face and dual innervation of the upper half of the face is critical when assessing facial weakness. Lesions that damage the motor cortex, such as acute ischemic strokes, will result in contralateral facial weakness of the lower face only, with preservation of the muscles of the upper face on both sides, due to the dual innervation of the upper face. Patients will have a weak smile, but will be able to close their eye tightly and wrinkle their forehead symmetrically. This pattern is often referred to as “central facial weakness,” because it’s caused by injury to the cerebral cortex, which is a part of the central nervous system.
