Case Study Template (3) (2)

docx

School

St. John's University *

*We aren’t endorsed by this school

Course

473

Subject

Health Science

Date

Nov 24, 2024

Type

docx

Pages

Uploaded by ProfComputer14290

Demographic Data : -Name: Joshua Worwitz -Age: 32 Years -Gender: male -Education: Master’s in Engineering -Occupation: Software Engineer -Marital Status: Married -Religion: Jewish Personal History : -Dietary Habits: the patient eats dietary meals but occasionally snacks on junks -Personal Hygiene: He maintains proper hygiene, brushes his teeth twice a day and takes daily showers. -Allergies: No known allergies -History of Past Illness: Had chickenpox as a child. No history of chronic disease -History of Present Illness: Developed flu like symptoms of sore throat and cough three weeks ago which he recovered after taking over the counter medication. Had feelings of tingling and numbness in feet and hands which spread to leg and arms a few days ago. Visited the ER after noticing trouble swallowing and weakness in facial muscles Head to Toe Examination : Vital Signs : -Temperature: 99 ° F -Pulse: 86 BPM -Respiratory Rate: 18 breaths peer minute -Blood Pressure: 140/90 mmHg

-Height and Weight: 6’ 00” and 180 lbs Skin : -color: Pale -moisture: Dry -temperature: Warm -turgor: Normal -lesions: None Nails : -color: Pink -shape: Normal Eyes : -visual acuity: 18/ 20 with glasses -sclera: White -pupils: Equal and reactive to light -eyelids: Droopy Ears : -hearing acuity: Normal -ear drum: Normal Nose: -external nares: Normal -discharge: None -sinuses: Tender -mucosa: Pink Neck: -neck muscles: Weak

-thyroid: Normal -lymph nodes: Nonpalpable -trachea: Midline Thorax/Lungs: -respiratory rate/rhythm: Normal -thoracic muscles: Normal -fremitus: Normal -percussion: Resonant -auscultation: Clear breath sounds -contour: Symmetrical Heart: -auscultation: Normal heart sounds -rate: 86 beats per minute -rhythm: Regular Neuro: -level of consciousness: Alert and oriented to person, place, time and situation -behavior: Cooperative, anxious -grip: Weak bilaterally -follows commands: Yes -PERRLA: Yes -facial symmetry: No, right side droops -gait: Unsteady, needs assistance Abdomen: -inspection: Flat, no distension -palpation: Soft, nontender, no masses

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

-percussion: Tympanic -auscultation: Normal bowel sounds Musculoskeletal: -inspection: Normal posture, no deformities -palpation: No tenderness, swelling, or crepitus -range of motion: Limited in lower and upper extremities due to weakness -tone/strength: Decreased in lower and upper extremities, 3/5 on both side Introduction/Description of Event : Joshua, a 32 yrs. old male software engineer who developed weakness and tingling in his limbs and face and presented to the emergency room. Two weeks ago, he reported having flu like symptoms and after assume over the counter medication they resolved. He did not have any allergies and chronic disease recorded in his medical history file. He is married and had a young son aged 5. He worked from home and loved playing video games, watching movies whilst relaxing. He smoked almost rarely and he drank occasionally. No family history of neurological disorders was present in him. Clinical Manifestations/Symptoms : Joshua exhibited signs and symptoms of Guillain-Barre syndrome (GBS), a rare disorder in which the immune system attacks the peripheral nerves, causing weakness, tingling and paralysis. His symptoms started in his feet and hands, and then ascended to his legs and arms. He also experienced difficulty walking, climbing stairs, and holding objects. He had weakness in his facial muscles, which affected his speech and swallowing. He had droopy eyelids (ptosis) and reduced facial symmetry. He had no sensory loss, pain, or bladder or bowel dysfunction . He was alert and oriented, but anxious about his condition. Diagnostic Tests and Findings : The following diagnostic tests were performed to confirm the diagnosis of GBS and rule out other possible causes of his symptoms: -Complete blood count (CBC): Normal -Blood chemistry: Normal

-Urinalysis: Normal -Chest X-ray: Normal -Electrocardiogram: Normal -Lumbar puncture: Increased protein and normal cell count in cerebrospinal fluid (CSF), which is consistent with GBS -Nerve conduction studies: Slowed nerve conduction velocities and prolonged distal latencies, indicative of demyelination -Electromyography: Reduced amplitude and duration of muscle action potentials, suggestive of axonal damage Diagnosis : From the history, physical examination and results from diagnostic tests Joshua was diagnosed with acute inflammatory demyelinating polyradiculoneuropathy; the most common form of GBS in North America and Europe. AIDP is characterized by muscle weakness, beginning in the lower extremities and moves upward to other parts of the body with demyelination affecting peripheral nerves. Course of Care/Treatment/Evaluation Joshua was admitted to ICU for close observation and support. He underwent an IVIG treatment and also got analgesics, anticoagulants and fluids when needed. A neurologist, pulmonologist, physical therapist and speech therapist assessed him daily. He underwent periodic tests for vital signs, lung capacity, nerve response as well muscle strength. He was encouraged to do passive and active exercises protect him from muscle atrophy, weakness as well as contractures. He was informed about his condition and prognosis and he received emotional support as well. Outcome : The patient responded positively to IVIG treatment and demonstrated steady improvement in his complaints. After fourteen days, the movement of his limbs could be conducted more freely and he walked with little support. His facial weakness and ptosis also got better. He was moved to a rehabilitation unit where his physical and speech therapy continued. His muscle strength and function returned to him largely after six months. He was able to resume his work and everyday life. His post recovery condition was devoid of any residual weakness numbness or pain. There was not any recurrence of GBS. He was told to prevent infections, vaccinations and arousing stress capable of causing relapse. He used to be followed regularly at the regular interval by his primary care physician and neurologist.

Case Study Template (3) (2)

Related Documents