Based on the patient’s history of a motor vehicle accident that happened 3 days prior to admission, and following chief complaints of neck stiffness and headache, I would first request an order for a CT of the brain and cervical spine to rule out brain injury and fractures of the neck. Also, the patient might be having a stroke or a concussion could be the cause, and therefore, a detailed assessment and testing must be done and presented to the Physician in order for them to give a clear plan of treatment and a diagnosis.
The patient symptoms does not indicate any sign of concussion, and therefore, this has to be ruled out during treatment. Signs of concussion include confusion, memory problem, dizziness, weird eye movement, nausea, balance problem, sensitivity to noise or light and post-traumatic vertigo that last for several hours tends to occur in Ménière disease (Healthline Media Editorial Team, 2017).
However, traumatic brain injury would be a possible diagnosis since the patient exhibits signs of profuse sweating which is related to traumatic brain injury, tumor, or hemorrhages of the medulla (Garg & Malhotra, 2016). In addition, whiplash would also be a likely diagnosis which common after MVAs. Whiplash is a less severe injury and treatment just takes a few months to recover. However, some patients develop “late whiplash injury syndrome,” and includes symptoms like neck pain, vertigo, tinnitus, hearing loss, and headache. Dizziness, hearing loss, and tinnitus are considered as the major ontological signs of whiplash (Reddy et al., 2018).
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In addition to imaging, it would be important to perform a detailed assessment of the cranial nerves in order to determine nerve damage. In the process, I will also ask if she is on any anticoagulants, which I would then request orders for blood analysis. After the process of assessment’s and testing is done and data is collected, it will be easier for the physician to study and determine a diagnosis for the patient. The treatment plan and interventions will be implemented thereafter.
References
- Garg, A., & Malhotra, R. (2016). Sweating Disorder after Traumatic Brain Injury. J Anesth Clin Res, 7(695), 2.
- Healthline Media Editorial Team (2017). Healthline Newsletter: Concussion. Retrieved from https://www.healthline.com/health/concussion
- Jarvis, C. (2016). Physical Examination and Health Assessment, 7th Edition. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9781455728107/
- Reddy, B. U., Pal, R., Ghosh, A., Moscote-Salazar, L. R., Reddy, V. V., & Agrawal, A. (2018). Tinnitus after traumatic brain injury: an overview. Romanian Neurosurgery, 32(2), 487-490.
