Assessing Neurological Symptoms Mr. XYZ

20 years old

White

S: Mr. XYZ complains of headaches (intermittent) that diffuse all over his head. He, however, points out that he experiences great intensity as well as pressure just above his eyes. The said pressure and intensity spreads through his nose, cheekbones and jaw.

O: Height: 71 inches

Weight: 186.3 pounds

Vital signs: T 96.5, P 63, RR 19, BP 123/75

General: patient cooperative and responsive.

HEENT: H – no injury observed, normocephalic skull; E – appropriate hearing; bilateral reddening of canals; E – visual acuity in each eye, patient has no blurred vision or diplopia; N – moist and reddened nasal mucosa, rhinorrhea creamy and colored, obstruction not noted; T – moist and pink oral mucosa, 1+ tonsils, patient does not confirm dysphagia, reddened pharynx.

Neck: thyromegaly not noted, no masses or tenderness noted.

Lungs and thorax: diaphragm excursion not measured. Resonant lungs and good expansion in thorax. Symmetric thorax. Vesicular breathing sounds noted.

Cardiovascular: S1 normal, S2 normal and no murmur .

Gastrointestinal: non-distended and non-tender abdomen, soft abdomen, normoactive bowel sounds.

Musculoskeletal: not assessed.

Endocrine: no diabetes or thyroid disease history.

A: Differential...

Diagnosis founded on the signs and symptoms presented. Examination presented swollen nasal tissue, rhinorrhea was colored and creamy.
Rhinitis (allergic) not supported by physical exam and symptoms. Patient did not present stuffy/runny nose.

P: #1 Biaxin 500 mg – oral administration – two tablets daily for 7 days.

#2: spray Rhinocort in each nostril on a daily basis.

#3: patient encouraged to rest and take lots of fluids for hydration purposes.

Part 2: Diagnostic Tests

When it comes to acute sinusitis, diagnosis is largely founded on physical exam and history. Some of the tests that could be conducted this front, according to Jaume, Quinto, Alobid, and Mullol (2018), include a nasal endoscopy, an MRI, and CT sinuses. While MRI and CT sinuses could both help indicate or assess the extent of the disease, the nasal endoscopy presents purulent discharge. The clinical symptoms associated with allergic rhinitis on the other hand “include excessive mucus production, congestion, sneezing paroxysm, watery eyes, and nasal and ocular pruritus” (Cevc, 2017). Presence of nasal polyps ought to lead to allergic tests such as the blood test or the skin prick test.

Part 3: Differential Diagnosis

Listed below are Mr. XYZ’s five different possible conditions for his differential diagnosis:

Condition…