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Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion

Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion

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Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion

Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion.

Week 3: Neurologic, Musculoskeletal, and Cardiopulmonary Assessment

Using a friend, family member, or colleague, perform a neurovascular (include all cranial nerves), musculoskeletal, and cardiopulmonary (includes the heart, lungs, and peripheral vasculature) exam. Document the physical examination findings in the SOAP note format.

Even though your patient may have abnormal findings, you must document the expected normal exam findings for the system. If you would like to include the abnormal findings they should be noted in parenthesis next to the normal expected findings. The complete subjective and objective sections must be included.  You may include the assessment and plan portion of the SOAP note, but these sections will not be graded.

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You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must use the chief complaint of headache, back pain, and cough. You should also focus the ROS based on the patient’s chief complaint and the body systems being examined. Refer to the SOAP Note Format document in Course Resources as necessary. This will be the same format that faculty will follow during the immersion weekend. Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion.

* There are videos of the exams to be performed at immersion in Modules → Introduction and Resources→ Immersion section. Also the immersion evaluation forms are located in the Course Resources section. They should be reviewed and practiced often.

 

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Tiffany Lunsford

Tiffany Lunsford 

Jul 16, 2017Jul 16 at 7:20pm

Manage Discussion Entry

Class, Welcome to week Three! This week, we are focusing on neurological, musculoskeletal and cardiopulmonary exams. Please follow the discussion question and grading rubric closely, I have also posted additional helpful guidance.  Please remember what goes in the ROS (Subjective) vs. the Physical Exam (Objective).

Here are the following course outcomes to assist in focusing this week:

3: Demonstrate knowledge required to perform a focused health history and examination for developmental, gender-related, age-specific, and special populations. (PO 1, 5)

6: Differentiate normal from abnormal findings. (PO 1, 4)

8: Adapt history and physical examination to the needs of the patient, i.e., pediatric versus geriatric patient (PO 1,4,7)

Class, I wish to give some extra guidance to practicing, performing the assessments and posting your assessment for Neurological, Musculoskeletal and Cardiopulmonary systems. These systems should include detail of what all findings (normal or if your patient is with abnormal findings) would include for each of the assigned systems. Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion.

When assessing the neurological system one area for example of detail would be cranial nerves which should include listing each one of them with some identification that shows that you know the assessment test for each cranial nerve. This detail should also be applied to other aspects of the Neurological examination such as finger to nose, heel to shin test, reflexes, level of consciousness, motor function etc…many more to include…please refer to both texts for other areas to be included.

Cranial Nerve example (not all inclusive): no deficit to sense of smell (Olfactory CN1) upon the patient patent nares through ability of sniffing bilateral nares, able to identify odors such as coffee and peppermint.

For Musculoskeletal, it goes beyond inclusion of range of motion and should include all maneuvers that show no deficits/deficits (upper and lower extremities, cervical spine- as well as other aspects of the MS exam).

MS example (not all inclusive): ballottement, bulge sign, phalen test, ROM all areas (with degrees), McMurray, valgus, drawer, noted or not noted Genu varum etc…..please refer to both texts for other areas to be included.

Cardiovascular example (not all inclusive): physical exam to the thorax, lungs, and vascular system. Many of you will be more comfortable with these areas because you have been wielding a stethoscope for some time.  However, learning things like whispered pectoriloquy and broncophony (not all inclusive items to include) take practice.

Please ensure to read assigned readings and watch the video for this week. Doing this assignment in such detail will help at Immersion weekend when you have to show knowledge of these assessments and how to perform each test!

Note about diagnosis/differential diagnoses: the primary diagnosis should be included in the assessment while if there are any other differential diagnoses being considered; students should list them in the treatment plan.

Dr. Lunsford

 

Collapse SubdiscussionSarah Gray

Sarah Gray

Jul 17, 2017Jul 17 at 3:16pm

Manage Discussion Entry

Dr. Lunsford and Classmates

Patient Information:

JNG,38, Male, Caucasian, United Healthcare

S.

CC “Headache, back pain and cough”

HPI:

Headache:

Onset: 1 week ago

Location: temporal area

Duration: on and off

Characteristics: throbbing and pressure feeling behind eyes

Aggravating Factors: reading and too much screen time

Relieving Factors: dark and quit room

Treatment: ibuprofen

Back pain:

Onset: 3 weeks ago

Location: Lumbar area both side of spine

Duration: present most of the time, worse in the morning

Characteristics: ache tight feeling, difficult to bend over at times, non-radiating

Aggravating Factors: sedentary time

Relieving Factors: going for a walk and stretching

Treatment: ibuprofen

Cough:

Onset: 3 days ago

Location: chest

Duration: on and off throughout day

Characteristics: dry nonproductive, self-limiting

Aggravating Factors: talking too much

Reliving Factors: rest and hydration

Treatment: none

 

Current Medications:

      • Nexium 2o mg daily for acid reflux
      • Chantix 0.5 mg per day for smoking cessation with 2 weeks left
    • Ibuprofen 400 mg every 6 hours as needed for back pain and headache

 

Allergies: no known allergies to food or drugs and no know allergy to a specific environmental allergy.

PMHx:

    • questionable GERD with no official diagnosis
    • appendectomy 30 years ago
    • wisdom teeth removed approx. 20 years ago
    • positive history of chicken pox, no other hospitalizations,
    • hepatitis B vaccine up to date, unknown last DTap
    • refused flu vaccine
    • high school graduate
    • every 6 month dental cleanings

Soc Hx: JNG is a waiter at a restaurant and a culinary arts student, playing guitar and writing music are JNG hobbies, rescued a puppy one year ago, he is a recovering alcoholic for 4 years and is working toward quitting smoking with Chantix, no other elicit drugs, JNG is married with no children, JNG states dinking an adequate amount of water and eats a healthy diet including fruits and vegetables, JNG used to run 3 miles 4 days a week but is no longer able to. He wears his seatbelt all the time, He lives in an apartment and smoke detectors and co2 detectors are in working order. JNG is red headed, fair complexion and has many freckles and regular use of sunscreen encouraged. Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion.

Fam Hx:

 

    • paternal grandfather: Barrett’s esophagus, PVD with amputation

 

    • Paternal grandmother: passed from unknown cancer
    • Maternal grandparents: unknown health history
    • Father: no health issues
    • Mother: alcoholic, tremors with undiagnosed reason, anxiety
    • Brothers: adopted with no health issues

ROS:

CONSTITUTIONAL:  No weight loss, fever, chills, sleep disturbances, night sweats, weakness or fatigue.

HEENT:

    • Head: no trauma or dizziness, headache present
    • Eyes:  No visual loss, blurred vision, double vision or yellow sclerae glasses present.
    • Ears: no hearing loss, dizziness, pain or discharge
    • Nose: present, no drainage,
    • Throat:  no bleeding gums, voice changes swallowing difficulty, or sore throat, dental appliance present

SKIN: no rash, many freckles noted

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema, dyspnea, orthopnea, syncope or edema, no leg pain or swelling,

RESPIRATORY:  No shortness of breath sputum. Nonproductive cough present, quit smoking 3 month ago after 20+ year pack a day,

GASTROINTESTINAL:  No anorexia, nausea, vomiting, melena or diarrhea, 1 soft BM every day, no jaundice,

GENITOURINARY:  no burning or frequency with urination, steady easy to start stream

NEUROLOGICAL:  No dizziness, syncope, paralysis, seizure, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. No difficulty speaking or swallowing

MUSCULOSKELETAL:  No muscle, joint pain or stiffness, swelling, instability, able to perform ADL’s and work safely, Lumbar region back pain Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety, Positive history of alcoholism

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis, worse congestion with outdoor time

O.

Physical exam:

Vital sign: BP 120/80, HR 84, RR 20, Temp 98.7 F, o2 sat 98% on RA

Constitutional: appears well developed, healthy weight, well kempt, alert and oriented x4

HEENT:

    • Head: appropriate size, shape, symmetry, scalp and hair well intact,

 

    • Eyes: PERRLA, intact extraocular movement, conjunctiva clear, red light reflex present
    • Ears: Bilat tympanic membrane gray, translucent and intact, no tenderness or inflammation, whisper test passed bilat, (wax present R>L)
    • Nose: no discharge, olfactory sense intact, (tenderness present over frontal and maxillary sinuses, inflammation noted bilat)
    • Throat: no erythema, drainage or abscess present, mucosa moist, gums intact, pharynx midline
    • Skin: no lesions, bruises or open areas, (scar to right lower quad of abdomen, rash to upper back)

Cardiovascular: Heart rate and rhythm regular, no murmur, click, rubS3, S4, or gallop present, no edema, no JVD, no visible pulsations, heave or lift present, Pulses present and palpable 2+, no carotid bruit, apical impulse present at 5th ICS MCL, extremities are warm and pink, no swollen lymph nodes,

Respiratory: Chest symmetrical, tactile fremitus equal bilaterally, no tenderness, lumps or lesions, resonance noted equally bilaterally, Lung sound clear without wheeze or rales, no SOB,

Gastrointestinal: abdomen soft and flat, bowel sounds present x 4, no bruit noted, liver span 12 cm, splenic dullness noted, not palpable, no CVA tenderness, no other organomegaly or masses noted

Genitourinary: No hernia, nodules, rashes, or discharge

Neurologic:

Mental status: Alert and oriented X4, answers question appropriately, recent and remote memory intact.

Cranial nerves:

    • I: olfactory nerve intact, able to smell alcohol pad
    • II: Vision 20/20 bilaterally, peripheral fields intact by confrontation, optic fundus normal bilaterally
    • III, IV, VI: extraocular movement by cardinal positions of gaze intact bilaterally, no ptosis or nystagmus noted, PERRLA with pupil size of 2mm, palpebral fissures equal bilaterally,
    • V: Sensation intact bilaterally throughout face and equal jaw strength
    • VII: facial muscles intact and symmetric with smiling and puffed check test
    • VIII: whispered words heard bilaterally
    • IX, X: swallowing intact with positive gag reflex, uvula and soft palate rises midline, voice smooth and unstrained
    • XI: shoulder shrug, head movement intact and equal bilaterally,
    • XII: tongue midline with no tremors, lingual speech clear

Motor Function: gait smooth and coordinated, tandem walk completed, negative arm drift with Romberg test, finger to nose and finger to finger smooth with eyes open and closed, no atrophy, weakness or tremors or contractures noted, full ROM of all extremities,

Sensation: sharp, light and vibration intact to all extremities, Stereognosis: able to identify a safety pin, Kinesthesia intact

Reflexes: bicep, tricep, brachioradialis, quadricep and Achilles reflex intact 2+, abdominal reflex intact, plantarflexion noted with plantar reflex

Musculoskeletal: No weakness, instability, gait disturbance, ROM intact and equal, no joint swelling, tenderness or redness, no spinal deviation, movement smooth with no crepitus noted, equal strength to all extremities and able to maintain flexion with resistance

Lymphatic: no enlarged lymph nodes, lymphedema

Psychiatric: appears calm and cooperative with exam, asking appropriate questions

In summary, this patient demonstrated a normal neurological and musculoskeletal exam with no worsening of symptoms. The headache relates mostly with a tension-type headache because there was no nausea, photophobia or phonophobia noted with migraines. Patients complaining of a headache that demonstrate a normal neurologic exam do not require further imaging or laboratory testing. Symptoms to take more seriously regarding a headache would include patient complains of first or worst headache, headache induced by cough or exertion, change in personality, older than fifty or tenderness over temporal artery (Hainer & Matheson, 2013). Managing his back would also not include imaging studies at this time but treatment with pharmacotherapy, cognitive behavior therapy, spinal manipulation and/or lifestyle modification should be initiated. NSAIDS and muscle relaxants would be my first choice but if ineffective an opioid would be indicated. I would request a CMP to ensure his kidneys are in good working order with his recent use of ibuprofen and before initiating NAIDS (Herndon, Zoberi, & Gardner, 2015)

 

References

Hainer, B. L., & Matheson, E. M. (2013). Approach to acute headache in adults. American Family Physician87(10), 682-687.

Herndon, C. M., Zoberi, K. S., & Gardner, B. J. (2015). Common questions about chronic low back pain. American Family Physician91(10), 708-714.

NR509week3soapnote.docx

 

Collapse SubdiscussionTiffany Lunsford

Tiffany Lunsford 

Jul 19, 2017Jul 19 at 8:18pm

Manage Discussion Entry

Hi Sarah,

What exam findings would you expect to find if this patient presented with pneumonia?

What are the current treatment guidelines for pneumonia treatment?

Dr. L

 

Collapse SubdiscussionSarah Gray

Sarah Gray

Jul 22, 2017Jul 22 at 10:41am

Manage Discussion Entry

Dr. Lunsford,

Symptom of community acquired pneumonia can include cough, dyspnea, pleuritic pain, fever, chills or malaise. Increased need for supplemental oxygen may also be noted and should prompt the provider to admit the patient to the hospital. Chest radiography is still the gold standard for diagnosing pneumonia but lung ultrasonography is better at differentiating between pleural effusions, pneumothorax, pulmonary embolism and pulmonary contusion. Assessment finding can also include increased fremitus, uneven chest expansions, dullness on percussion and crackles on auscultation. The most commonly used assessment tool to determine treatment location is the CURB-65, patients with a score of 0-1 can me managed in the outpatient setting. Antibiotic therapy in the outpatient setting can include macrolides and fluoroquinolones if there was antibiotic exposure in the last three months followed by a beta-lactam plus macrolide.  A five-day course is sufficient for a low-severity pneumonia based on the CURB-65 score and 10 days for moderate severity (Kaysin & Viera, 2016).

 

References

Kaysin, A., & Viera, A. J. (2016). Community-acquired pneumonia in adults: Diagnosis and management. American Family Physician94(9), 698-706.

 

Tiffany Lunsford

Tiffany Lunsford 

Jul 23, 2017Jul 23 at 8:04pm

Manage Discussion Entry

Hi Sarah,

Really great discussion here, especially about the recommended antibiotic treatment. Keep this handy, because I am confident you will see this in clinicals next semester.

Dr. L

 

Lacie Emerine

Lacie Emerine

Jul 21, 2017Jul 21 at 9:09am

Manage Discussion Entry

Great post, Sarah.

I agree, JNG’s complaint of head pain is most consistent with a tension headache. Tension headaches are the most common type of headache. Triggers for a tension headache include: physical/emotional stress, alcohol, caffeine (too much or withdrawal), minor illnesses, eye strain, dental issues, excessive smoking, and/or fatigue. JNG should be encouraged to avoid headache triggers and take OTC medications such as aspirin, ibuprofen, or acetaminophen. Narcotics and muscle relaxers may also be prescribed if OTC medications were ineffective.  I would be careful with acetaminophen usage with this patient due to his past history of alcoholism since frequent use of acetaminophen can damage the liver. Other non-medical therapies can be used as well, such as: relaxation, stress-management training, massage, biofeedback, and acupuncture (U.S. National Library of Medicine, 2016).

As JNG’s provider, I would want to investigate into the frequency of this headache. If he is experiencing at least 10 episodes 1-14 days/month on average for > 3 months, then we could further classify these tension headaches as frequent episodic. I would want to follow up to see if the headache was managed effectively with ibuprofen as reported, if not medications could be adjusted. If medications remained ineffective for these headaches, it may be in the best of interest to refer him to a neurologist (Hollier, 2016).

Hollier, A. (2016). Clinical guidelines in primary care (2nd ed.).Advanced Practice Education Associates.

U.S. National Library of Medicine. (2016). Tension headache. Retrieved from https://medlineplus.gov/ency/article/000797.htm

 

Collapse SubdiscussionLacie Emerine

Lacie Emerine

Jul 18, 2017Jul 18 at 8:09am

Manage Discussion Entry

Patient Information:

            M.E., 60-year-old, Caucasian, Male, Medical Mutual

S.

Chief Complaint: “I’ve got this cough with back pain and a headache”.

HPI

            Onset: “Cough started first about a week ago, then back and head started hurting “a few days later”

            Location: Upper back pain and headache “feels pressure around my nose and eyes”

            Duration: For the last week

            Characteristics: Dry cough, patient reports pain when coughing into his upper back and head throbbing.

           Aggravating Factors: Ambulating, Daily tasks, Coughing

            Relieving Factors: Hot shower, water, and rest

            Treatment: Sudafed OTC with minimal relief

Current Medications:

    • Valsartan 160mg 1 tab PO daily for high blood pressure
    • Amlodipine 5mg 1 tab PO daily for high blood pressure
    • “Some water pill”, unsure of name or dosage, but takes 1 tab PO daily
    • Fish Oil and Vitamin C (daily, unsure dosage)

Allergies: NKDA or food/environmental allergies

PMHx: 

Patient reports history of asthma, joint pain, hypertension. Reports being UTD on all immunizations that he knows of without the annual influenza vaccine. When asked about last tetanus vaccine, patient is unsure. Reports tearing left knee cartilage at age 15. Patient reports basal cell carcinoma removed from nose and left elbow in 2005.

Soc Hx:

Patient is a 60-year-old Male who works full-time as an accountant and financial advisor for the last 28 years. Reports working inside in an office locally in his home town. Reports typical work week of 50+ hours. Reports living with his wife of 34 years.  Has a 36-year-old daughter and a 31-year-old son who are both married and living outside of the home with their families. Patient reports drinking beer and liquor socially, but denies current tobacco use. Reports previous smoker of 1-2 PPD for 8 years, but quit when he was 25 years old. He has a 12 pk year (roughly estimated at 1.5 PPD) smoking history. He reports always wearing a seat belt while in an automobile. He reports have working smoke detectors throughout his home along with a carbon monoxide detector.

Fam Hx:      

    • Mother: died at 88 years old, “extreme high blood pressure”, CHF, MI
    • Father: unknown, (patient reports father died when he was 3 years old)
    • Unsure about grandparent history on either side
    • Brother: died at age 70. MI at age 40. Also, HTN, CHF, Agent Orange exposure
    • Brother: 75 years old, Type II Diabetic, Polio as a child
    • Brother: 65 years old, Type II Diabetic
    • Sister: 72 years old, “heart issues”

ROS:

CONSTITUTIONAL: No weight loss, fever, chills. Patient reports constant fatigue for as long as he can remember.

HEENT: Eyes: no visual loss, double vision, or yellow sclera. Patient reports blurry vision and excessive watering for “some time”. Ears, Nose and Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: Patient reports dry cough over the last week. Reports often wheezing with some shortness of breath. No sputum.

GASTROINTESTINAL: No abdominal pain, nausea, anorexia, vomiting, diarrhea, constipation, or blood in the stool.

GENTITOURINARY: No burning, tingling or pain with urination. Patient reports increase in frequency.

NEUROLOGICAL: Report headache someone in the last week with pressure above eyes and around nose. Denies feeling dizzy, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: Pt denies any recent injury, but does report generalized muscular aches and pains to all joints. Denies joint stiffness. Reports upper back pain since coughing.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged lymph nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: History of asthma. No history of hives, eczema, or rhinitis.

O.

Vital signs: Temperature 97.4 F, BP 142/83 mm Hg (sitting), Pulse 68 bpm, Resp. 20/min, Height 69 inches (5’9), Weight 330 lbs. (149 kg)

Physical exam: 

CARDIOVASCULAR: No cardiomegaly or thrills, regular rate and rhythm, S1 and S2 normal. No murmur or gallop. No JVD present.

RESPIRATORY: Good expansion without retractions. Non-tender. Clear to auscultation and percussion bilaterally. (Expiratory wheezing heard upon auscultation)

NEURO: Alert and oriented x3. GCS 15. Cranial nerves II-XII intact. Sensation to pain, touch, and proprioception normal. Deep tendon reflexes normal in upper and lower extremities. No pathologic reflexes. The sensory examinations are normal, with pain, light touch, and stereognosis intact. Cerebellar function is normal. Speech is clear. Gait normal.

MUSCLOSKELETAL: Normal gait and station. Full ROM. No misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions, decreased range of motion, instability, atrophy or abnormal strength or tone in the head, neck, spine, ribs, pelvis or extremities. Good strength bilaterally. No clubbing, cyanosis or edema. Peripheral pulses are intact, sensation intact. (Patient has limited ROM with left ankle and turning his neck to the right side)

(Swartz, 2014).

Diagnostic results: N/A

A.

N/A

P.

N/A

In summary, this patient presents with a cough that started around 1 week ago with upper back pain and a headache. It seems like these symptoms are all related and the back pain and headache are caused from the coughing, but as an inexperienced provider I feel like more serious conditions need ruled out as well with this visit. According to Maheshwari and Pandey (2012), most headaches are benign in nature, but nearly 10% of all headaches are secondary to an underlying pathologic condition; therefore, I would need to pay close attention to what my patient is telling me and what I am seeing during my head-to-toe assessment. A potential diagnosis could be a primary cough headache, which his bilateral and affects predominantly patients over the age of 40. Primary cough headaches are often seen after a respiratory infection (Maheshwari & Pandey, 2012).

Even though this patient reported no environmental allergies, with his itchy and watery eyes, another diagnosis could be sinusitis or acute viral rhinopharyngitis (common cold). Regardless, a thorough HEENT exam should be performed. Other things that caught my eye during this encounter was the patient’s BP of 142/83 which I feel is elevated after being on two different antihypertensive medications, this may need to be re-evaluated. The patient also reports going to the bathroom more frequently and always feeling fatigued; I’d like to investigate this further with some lab work such as CBC, BMP, UA, possible chest x-ray and an EKG with his family history.

Maheshwari, P., & Pandey, A. (2012). Unusual headaches. Annals Of Neurosciences, 19(4), 172-176. doi:10.5214/ans.0972.7531.190409

Swartz, M. H. (2014). Textbook of physical diagnosis: History and examination (7th ed.). Retrieved from http://bookshelf.vitalsource.com

 

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