Neurologic, Musculoskeletal, and Cardiopulmonary Assessment

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.

This topic was locked Jul 23 at 11:59pm.

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

Sample 1

Patient Information:

JNG,38, Male, Caucasian, United Healthcare

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

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 Physician, 87(10), 682-687.

Herndon, C. M., Zoberi, K. S., & Gardner, B. J. (2015). Common questions about chronic low back pain. American Family Physician, 91(10), 708-714.

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 Physician, 94(9), 698-706.

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

Sample 2

Patient Information:

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

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.

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

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

Further assessment of Cranial Nerves I-XII, which are all intact:

Cranial Nerve I (Olfactory): patient correctly identified smell of mint with one nostril occluded, vice versa.

Cranial Nerve II (Optic): 20/30 per Snellen chart, PERRLA

Cranial Nerve III (Oculomotor), Cranial Nerve IV (Trochlear), & Cranial Nerve VI (Abducens): Extra Ocular Movements lateral.

Cranial Nerve V (Trigeminal): patient able to close eyes and verbalize equal touch to face. Patient able to bench teeth and move jaw without any issues.

Cranial Nerve VII (Facial): facial symmetry noted.

Cranial Nerve VII (Acoustic): Whisper test passed without difficulty.

Cranial Nerve XII (Hypoglossal), Cranial Nerve X (Vagus), & Cranial Nerve IX (Glossopharyngeal): Patient able to move tongue freely with uvula midline and symmetrical palate. Patient able to speak clearly and swallow.

Cranial Nerve XI (Spinal Accessory): head movement symmetrical, shoulder shrug intact.

Dr. Lunsford,

Thanks for your feedback. I have added to my cardiac and respiratory assessments in italics below. With M.E.’s chief complaints, ROS, and my assessment, I feel M.E. is suffering from sinusitis or the common cold with complaints of a cough. To manage these symptoms, I would encourage M.E. to use an OTC antihistamine for his itchy watery eyes, such as hydroxyzine 25mg 3-4 times a day and possibly a decongestant. An analgesic such as Acetaminophen 325mg every 4-6 hours PRN should alleviate this patient’s headache and back pain caused from coughing. I would be hesitant to suggest a cough suppressant because these types of medications have not been shown to be helpful for most patients. In addition, coughing can be a good response to help clear the bronchi of mucus (De Blasio, Virchow, Polverino, Zanasi, Behrakis, Kilinc, Lanata, 2011). I would also ensure M.E. was practicing proper hand hygiene, gets adequate rest, manages stress appropriately, and humidifies his air (Hollier, 2016).

CARDIOVASCULAR: No cardiomegaly or thrills, regular rate and rhythm, S1 and S2 normal. No murmur or gallop. No JVD present. Precordium: no abnormal pulsations, no heaves. Apical impulse at 5^th ICS in left MCL, no thrills. S1-S2 are not diminished or accentuated, no S3-S4. Extremities are pink, warm, and dry. No edema present. All pulses 2+ and regular.

RESPIRATORY: Good expansion without retractions. Non-tender. Clear to auscultation and percussion bilaterally. No distress noted. AP < transverse diameter. Chest expansion symmetric. Tactile fremitus equal bilaterally. Lung fields resonant. Diaphragmatic excursion 4cm and equal bilaterally. (Expiratory wheezing heard upon auscultation) (Jarvis, 2016).

De Blasio, F., Virchow, J. C., Polverino, M., Zanasi, A., Behrakis, P. K., Kilinç, G., … Lanata, L. (2011). Cough management: a practical approach. Cough (London, England), 7, 7. http://doi.org/10.1186/1745-9974-7-7Links to an external site.

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

Jarvis, Carolyn. (2016). Physical examination & health assessment (7th ed.). St. Louis, MO: Elsevier.

Dr. Lunsford,

Physical examination findings in acute bronchitis vary, but many include: diffuse wheezes with use of accessory muscles, coughing, diffuse diminution of air intake or inspiratory stridor, sustained heave along the left sternal border, clubbing on the digits and peripheral cyanosis, bullous myringitis, and conjunctivitis, adenopathy, and rhinorrhea (American Lung Association, 2017; Fayyaz, 2017). I would treat this patient by mainly managing his/her symptoms. I would encourage the patient to avoid environmental irritants, recommend possible cough suppressants, bronchodilators, NSAIDs, antitussives/expectorants, and/or a mucolytic. According to Fayyaz (2017), in healthy individuals, antibiotics have not shown to be beneficial for treatment in acute bronchitis. Antibiotics may be considered if comorbidities pose a risk of serious complications, aged 65 or older with acute cough who have been hospitalized in the past year (have diabetes or CHF or are receiving steroids), and/or acute exacerbations of chronic bronchitis (Fayyaz, 2017).

American Lung Association. (2017). Acute bronchitis. Retrieved from http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/acute-bronchitis/managing-and-preventing-acute-bronchitis.htmlLinks to an external site.

Fayyaz, J. (2017). Bronchitis. Retrieved from http://emedicine.medscape.com/article/297108-overview

Sample 3

B.W., 54, M, Caucasian, Medical Mutual

CC: Headache, back pain, and cough

HPI:

Onset: 3 days ago

Location: Headache in the front of the head, lower back pain, and cough

Duration: Headache for 2 days, back pain for 3 days, and cough for 2 days

Characteristics: Tightness and pressure in the head, dull and achy back pain which is constant and non-productive cough which is intermittent

Aggravating Factors: Bright lights and movement for the headache, movement and lifting for the back pain, morning and night for cough

Relieving Factors: Dark rooms, Excedrin, rest, and cough suppressants

Treatment: Excedrin 2 tablets every 6 hrs PRN, Ibuprofen 400 mg PRN, and Halls cough drops PRN

Current Medications:

Excedrin 2 tablets every 6 hrs PRN for headache

Ibuprofen 400 mg every 4-6 hours PRN for back pain

Xanax 0.25 mg daily PRN for anxiety

Halls cough suppressants PRN

Allergies: NKA

PMHx: Hyperlipidemia and anxiety

No hospitalizations or surgeries

Seasonal flu vaccine 10-21-2016

Last tetanus vaccine 7-13-2011

Soc Hx:

Manager at a production factory for construction equipment

Enjoys riding his motorcycle, cooking, and trying new restaurants

Married with 2 grown children who do not live at home

Denies the use of tobacco and drugs, and socially uses alcohol once to twice a week consuming 2-6 beers total

High school education

Heterosexual

Fam Hx:

Mother-HTN, breast CA

Father-Hyperlipidemia, MI, HTN

Brother- Anxiety and hyperlipidemia

Paternal grandmother deceased from “old age”

Paternal grandfather deceased from MI

Maternal grandmother deceased from PN

Maternal grandfather deceased from alcoholic cirrhosis

ROS:

CONSTITUTIONAL: No weight loss, fever, chills, weakness or fatigue.

HEENT: No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, 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: Positive for non-productive cough. No shortness of breath or sputum production.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINAY: No burning on urination.

NEUROLOGICAL: Positive for headache. No dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: Positive for back pain. No muscle, joint pain or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

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

PSYCHIATRIC: Anxiety. No history of depression.

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

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

HEENT:

Head: Normocephalic and symmetric. Facial features are symmetric. No enlarged lymph nodes or thyroid gland.

Eyes: 14/14 bilateral eyes using Jaegar chart with glasses on. EOMs intact. Corneal light reflex symmetric bilaterally. PERRLA. No discharge.

Ears: Symmetric bilaterally. External canals are clear with no redness or discharge. TMs are pearly gray with light reflex. No pain with palpation.

Nose: Symmetric. Nares patent. Mucosa pink with no discharge or lesions. No septal deviation or perforation. No tenderness to sinuses with palpation.

Throat: Tonsils 2+. No exudate. Pharyngeal wall pink.

Mouth: Mucosa and gingivae pink, no lesions.

SKIN: Color pink with even pigmentation. Warm to touch, dry, smooth, and even. Turgor good, with no lesions.

NEUROVASCULAR:

Mental status: Appearance, behavior, and speech appropriate; alert and oriented to person, place, and time; recent and remote memory intact.

Cranial nerves:

I: Olfactory-Correctly identified alcohol with both nares

II: Optic- Vision 14/14 left eye, 14/14 right eye with glasses; peripheral fields intact by confrontation; fundi normal.

III ( Oculomotor), IV (Trochlear), & VI (Abducens) – EOMs intact, no ptosis or nystagmus; pupils equal, round, react to light and accommodation (PERRLA).

V: Trigeminal- Sensation intact and equal bilaterally; jaw strength equal bilaterally.

VII: Facial- Facial muscles intact and symmetric.

VIII: Acoustic-Whispered words heard bilaterally.

IX (Glossopharyngeal), X (Vagus), & XII (Hypoglossal) – Swallowing intact, gag reflex present, uvula rises in midline on phonation, tongue protrudes midline, no tremors.

XII (Spinal) – Shoulder shrug, head movement intact and equal bilaterally.

Motor: No atrophy, weakness, or tremors. Rapid alternating movements—finger-to-nose smoothly intact. Gait smooth and coordinated, able to tandem walk, negative Romberg.

Sensory: Pinprick, light touch, vibration intact. Stereognosis—able to identify key.

Reflexes: Normal abdominal, no Babinski sign, DTRs 2+ and = bilaterally with downgoing toes.

CARDIOVASCULAR:

Neck: Carotids’ upstrokes are brisk and equal bilaterally. No bruit.

Precordium: Symmetrical with no pulsations, heave, or lift.

Palpation: Apical impulse in 5^th ICS at left midclavicular line, no thrill.

Auscultation: Rate 79 bpm, regular rhythm, S1S2 are crisp with no S3 or S4 or extra sounds, no murmur.

Peripheral vasculature: Extremities are pink without redness or cyanosis. Extremities are symmetric without swelling or atrophy. Warm to touch and equal bilaterally. All pulses present, 2+, and equal bilaterally. No lymphadenopathy.

RESPIRATORY:

Inspection: AP > transverse diameter. Resp 15/min, relaxed, and even.

Palpation: Chest expansion symmetric. Tactile fremitus equal bilaterally. No tenderness. No lumps or lesions.

Percussion: Resonant to percussion over lung fields. Diaphragmatic excursion equal bilaterally.

Auscultation: Vesicular breath sounds clear over lung fields and equal bilaterally. No adventitious sounds.

MUSCULOSKELETAL: Joints and muscles symmetric; no swelling, masses, deformity; normal spinal curvature. No tenderness to palpation of joints; no heat, swelling, or masses. Full ROM; movement smooth, no crepitus, no tenderness. Muscle strength—able to maintain flexion against resistance and without tenderness, 5/5.

GASTROINTESTINAL: Abdomen soft, round, and non-distended. Symmetric bilaterally. Bowel sounds present, no bruits. Tympany in all 4 quadrants. No organomegaly, no masses, and no tenderness.

B.W. is suffering from headache, back pain, and cough. The headache and cough could be due acute sinusitis. The back pain could be due to a pulled muscle from lifting materials at work. Acute sinusitis occurs when the mucous membranes in the cavities become inflamed or swollen. This can be due to virus, allergy, or any other reason the drainage pathway is blocked. A person with acute sinusitis may suffer from “pressure or fullness around the nose, behind of between your eyes, or in your forehead” (Goodman, 2013, p. 837). They may also suffer from a cough, stuffy nose, decreased sense of smell, and possible nasal drainage.

B.W. would have a complete HEENT assessment and an abdominal assessment due to the back pain. Abdominal pain can radiate to several placed on the body. If the abdominal assessment were negative, then this writer would suggest a possible PT referral if the back pain continued. If the abdominal assessment were positive for tenderness or a mass, this writer would suggest imaging such as a KUB or CT. B.W. should continue to rest and drink plenty of fluids. He should continue to take his OTC Excedrin, Ibuprofen, and Halls as needed. He could also try using a saline nasal spray if he has any nasal congestion. He would require other interventions if his abdominal assessment and test were positive.

Reference

Goodman, D., Lynm, C., & Livingston, E. (2013). Adult sinusitis. American Medical Association, 309(8), 837-837.

Sample 4

Week 3 SOAP Note

Patient Information:

, 38, Female, Caucasian, BCBS-IL

CC (chief complaint) “headache, back pain, and cough”

HPI: Onset: “three days ago”

Location: frontal headache, mid-to-low back pain, productive cough.

Duration: three days

Characteristics: throbbing frontal headache, back pain which increases with cough, and cough with white-to-yellow sputum.

Aggravating Factors: headache and back pain increase with cough

Relieving Factors: Hot showers lessen headache and cough, OTC acetaminophen relieves headache and back pain

Treatment: OTC acetaminophen, rest, hot showers

Current Medications: acetaminophen, 650 mg, q6h; metoprolol tartrate, 50 mg., BID, St. John’s Wort, 900 mg., BID

Allergies: NKDA

PMHx: Vaccinations: Influenza 2016, Tetanus 2014; hypertension, appendectomy 1990 Soc Hx:Administrative Assistant, divorced, no children, drinks alcohol socially, non-smoker, denies past or current illicit drug use, sleeps 9 hours per night, wears seat belt at all times, working smoke detectors present in home.

Fam Hx: Paternal Grandfather (deceased, cardiac arrest): HTN; Paternal Grandmother (deceased): diabetes; Maternal Grandfather (deceased, cardiac arrest): HTN, COPD, CHF; Maternal Grandmother (alive): hypercholesterolemia; Father (alive): HTN, pre-diabetes; Mother (alive): HTN

ROS:

CONSTITUTIONAL: No weight loss, fever, chills, weakness or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat. (“I have a bad headache if I don’t take Tylenol at least every 6 hours and my nose has been running some.”)

SKIN: No rash or itching.

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

RESPIRATORY: No shortness of breath, cough or sputum. (“I have been coughing for the past three days. Sometimes there is a whitish or yellowish spit.”)

GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: No frequency or burning on urination. No pregnancies. Last menstrual period, 07/05/17.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. (“I have a bad headache if I don’t take Tylenol at least every 6 hours.”)

MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness. (“My back hurts, halfway down and my lower back, mostly when I cough.”)

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety. (History of depression. “I take St. John’s Wort and it helps.”)

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

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

Physical exam:

CONSTITUTIONAL: Ill-appearing female of childbearing age who denies weight loss, fever, chills, weakness or fatigue.

HEENT:

Head: Normocephalic, no lesions, liumps, scaling, parasites, or tenderness. Face symmetric , no weakness, no involuntary movements. (Tenderness on palpation of frontal and maxillary sinuses. Rhinorrhea present.)

Eyes: Visual acuity intact, EOMs intact, no nystagmus. No ptosis, lid lag, discharge, or crusting. Corneal light reflex symmetric, no strabismus. Conjuctivae clear. Sclera white; no leasions or redness. Pupils 3 mm resting, 2 mm constricted and equal, bilaterally. PERRLA.

Ears: No mass, lesions, scaling, discharge, or tenderness to palpation of pinna. Canals clear. Tympanic membrane pearly gray, landmarks intact, no performation. Whispered words heard bilaterally.

Nose: No deformities or tenderness to palpation. Nares patent. Mucosa pink; no lesions. Septum midline; no performation. (Rhinorrhea present.)

Mouth: Mucosa and ginivae pink; no lesions or bleeding. Dentition in good repair. Gingivae pink without edema, erythema, or lesions noted. Tongue symmetric, protrudes midline, no tremor. Pharynx pink; no exudate. Uvula rises midline on phonation. Tonsils 1+. Gag reflex present.

Neck: Supple with full ROM. Symmetric; no massess, tenderness, lymphadenopathy. Trachea midline. Thyroid nonpalpable, non-tender. Jugular veins flat at 45 degrees. Carotid arteries 2+ and equal bilaterally; no bruits.

SKIN: Uniformly tan-pink in color, warm dry, intact; turgor good. No lesions, birthmarks, edema. Nail beds pink with good capillary refill.

CARDIOVASCULAR: No thrills, murmurs, clicks, or gallops heard. No abnormal pulsations, lifts, or heaves noted. No JVD. All pulses 2+ and equal in all extremities. No bruits.

RESPIRATORY: Respirations unlabored, even, and without distress. Vesicular breath sounds heard throughout without adventitious sounds noted. Chest expansion symmetric. (Productive cough exacerbated with deep breathing during exam.)

GASTROINTESTINAL: Flat, symmetric. Skin smooth with no lesions, scars, or striae. Bowel sounds present, no bruits. Tympany in all four quadrants. Abdomen soft; no organomegaly; no massess or tenderness; no inguinal lymphadenopathy.

GENITOURINARY: External genitalia without lesions. Introitus normal, vaginal walls pink and moist without lesions or evidence of trauma. There is no cervical motion tenderness and the adnexa are without masses. There is no abnormal discharge from the cervix.

NEUROLOGICAL: Alert and oriented to person, place, and time. No mental status deficits noted. Cranial nerves intact. Babinski negative. Romberg negative. No motor deficits noted. No atrophy, weakness, or tremors.

MUSCULOSKELETAL: Normal gait. Joints with full ROM without pain, without deformities. Spine with full ROM and curvature normal. No paravertebral tenderness. Able to mantain flexion against resistance without tenderness.

HEMATOLOGIC: No bleeding or bruising noted.

LYMPHATICS: No enlarged nodes.

PSYCHIATRIC: Normal mood and affect. Intact judgment and insight.

Diagnostic results: Tests performed at today’s visit will include a CBC to rule out infectious process.

Utilizing the data received in the subjective and objective portions of this assessment, and the patient’s stated complaints, I would consider the following differential diagnoses: sinusitis, upper respiratory infection (viral vs. bacterial), and lumbar strain.

My plan is to educate this patient regarding acetaminophen dosing. While she reports that she is staying within the guideline of no more than 4 grams of acetaminophen in a 24-hour period, she did make a statement during the review of systems indicating her headache is controlled if she takes it “at least every 6 hours”. I would encourage her to continue using acetaminophen to relieve the headache and back pain. I would also suggest that she try adding and OTC decongestant to help relieve the headache, rhinorrhea, and productive cough. In this regard, education would also include the necessity of reading a list of ingredients on all OTC medications, to ensure that the patient is not taking a combination decongestant/pain reliever that might also contain acetaminophen along with her current dose of acetaminophen.

Because this patient has reported the use of St. John’s Wort for treatment of depression, I would also consider offering some homeopathic suggestions to this patient. Lambeau (2016) suggests “camphor, eucalyptus, and menthol also provide symptomatic relief of nasal congestion and cough when applied to the chest or neck” (p. 95). Lambeau (2016) also states that zinc may reduce the duration of an upper respiratory infection, while honey can be used to relieve a cough (p. 95).

As mentioned earlier, I would order a CBC for this patient. The CBC would advise me of any infectious process. I would decline to prescribe antibiotics for this patient at this time.

References

Lambeau, K., (2016). Cold and cough symptom relief. The clinical advisor: For nurse practitioners, 19(1), 94-96.

Dr. Lunsford,

As stated in my initial response, I would expect to find dyspnea and, most likely, wheezing in an exacerbation of COPD. Miravitlles, Anzueto, and Jardim (2017) include cough, wheezing, dypsnea, sputum production, or chest discomfort/tightness as possible symptoms of an exacerbation of COPD (pp. 4-5). According to the same study, “in many cases, exacerbations are triggered by respiratory tract infections (predominantly viral, but also bacterial) and environmental factors such as air pollution” (p. 1). Should I suspect a COPD exacerbation in my patient, it would serve the patient well for me to not only treat the exacerbation, but also to interview the patient further, in an attempt to determine a probable cause for the exacerbation.

Sample 5

CC (chief complaint) Headache, cough, stuffy/ runny nose, sore throat, and muscle aches for the past three days. Low back pain off and on for the past two to three months.

HPI:

Onset: Sore throat started four days ago, and three days ago, started with a headache, cough, stuffy nose, and muscle aches. “My sister in law had the same symptoms a week ago”. Intermittent low back pain started two to three months ago, while she was moving, and lifting heavy boxes and furniture.

Location: Muscle aches are all over. Feels a constant headache over her forehead and around her eyes. Low back pain/ache.

Duration: Headache, cough, stuffy/runny nose, sore throat, and muscle aches started three days ago. Low back pain started two or three months ago. “I’m not really sure when it actually started”.

Characteristics: feels sick and more tired than usual. “I don’t feel like eating, just not hungry”. Low back pain feels like a deep ache or pulling sensation at times.

Aggravating Factors: “I feel worse the longer I’m up and about”. Back pain is worse when lifting or “if I overdo it in day”.

Relieving Factors: Resting, sleep, and NyQuil help my cold. Naproxen and heating pad help my lower back. I only use them when it hurts.

Treatment: NyQuil every six hours. Naproxen 250mg as needed for back pain.

Current Medications:

Gabapentin 300 mg at bedtime as needed for hot flashes

Naproxen 250mg twice a day as needed for pain

NyQuil two capsules orally every six hours

Allergies: Penicillin-hives

Denies any environmental or food allergies

PMHx: Immunizations: As far as she knows she’s up to date on her immunizations. Influenza 9/2016.

Denies any medical history other than menopausal hot flashes.

Past surgical history

1. Right carpal tunnel release 12/20/2013 and revision done 7/2014- Dr. Durant at NMC
2. Left carpal tunnel release 01/25/2015 Dr. Durant at NMC
3. Trigger finger release bilaterally thumbs last done 7/2014.- Dr. Durant at NMC
4. Trigger finger releases bilaterally middle and ring fingers last done 10/2016- Dr. Durant at NMC.
5. 2009 mass removed from parotid gland by Dr. Brundage
6. 11/2008 inner ear surgery “a prosthesis was placed”
7. Cryotherapy for abnormal pap “years ago”
8. Lasix surgery bilaterally 2005

Soc Hx: Works as a medical assistant at a cardiology clinic. Divorced with two adult sons and one granddaughter. Loves to work outside in her yard and garden. Former smoker- quit in 1985, smoked ½ pack a day for 3 years. Alcohol use- 2 glasses of wine a day. No other recreational drug use. Does not use sunscreen when outside. Wears seat belts when in car. Owns her own home and has smoke and carbon monoxide detectors. Walks a couple of times a week. Eats a well-balanced diet.

Fam Hx:

Maternal grandmother- deceased at unknown age and cause

Maternal grandfather- deceased in his 90’s from unknown cause

Paternal grandmother- deceased in her 80’s from unknown cause

Paternal grandfather- deceased unknown age from unknown cause

Mother- deceased at age 87 from “natural causes”

Father- deceased at age 85 from “natural causes”. Had heart bypass surgery at some point.

One brother with prostate cancer

Both sons are healthy without any known health issues

ROS:

CONSTITUTIONAL: Denies unintentional weight loss (is dieting), fever, chills, or weakness. Feels fatigued.

HEENT: Head: Headache over forehead and around eyes for the past two days, feels a constant pressure with some relief from NyQuil. Does not usually have headaches. Denies dizziness, lightheadedness, or any head injuries. Denies any masses, lumps, or tenderness in head or neck. Denies difficulty swallowing. Eyes: Denies visual loss, blurred vision, double vision, pain, burning, itching or yellow sclerae. Denies floaters or flashes of light. Denies dry eyes or excessive tearing. Wears reading glasses to read. Can see distances. Glaucoma/eye exam done yearly. Ears: Denies ear pain, infections, discharge, tinnitus, vertigo, or hearing loss (had a normal hearing screening two years ago). Nose: Denies any sinus pain/pressure or trauma to her nose. Denies sneezing or nose bleeds. Clear watery runny nose except in the morning when it can be a thick yellow. Mouth and throat: Denies any sores or lesions, bleeding gums or toothaches (last dental cleaning- 3/2017). Sore throat the last three days and feels voice may be a little hoarse.

SKIN: Denies itching. Small rash by ankle. Denies birthmarks. Tattoo left shoulder. Denies having any moles or history of skin infections or rash. “I have freckles”. Denies hair loss or change in finger or toe nails. Denies dry or oily skin or excessive diaphoresis.

Breasts: Last mammogram was 11/2017. Does not perform monthly self-breast exams. Denies any skin changes or nipple discharge.

CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. Denies shortness of breath, difficulty lying flat, changes in skin color, palpitations, or edema.

RESPIRATORY: Denies shortness of breath or chest pain with breathing. Denies any lung disease or history of smoking. C/O mainly a dry cough, but “I may bring up some yellow stuff, after I’ve swallowed some”. Cough started three days ago.

GASTROINTESTINAL: Denies any abdominal pain, nausea, vomiting, diarrhea, constipation or changes in bowel habits. “I don’t have much interest in food the last four days”. Began with onset of sore throat.

GENITOURINARY: Denies burning on urination. Gravid 2 Para 2, both vaginal deliveries. Last period was in 2015. Had reddish spotting for three to four days 2/2017. Gyn exam by Dr. Peterson with pap smear and ultrasound done. Hot flashes daily with difficulty sleeping at night.

NEUROLOGICAL: Denies history of head injury or seizures. Denies dizziness/lightheadedness, passing out, weakness, balance issues, numbness/tingling, difficulty swallowing or speaking. No changes in the ability to urinate or bowel control. Denies difficulty remembering things. Headache over forehead and around eyes that started three days ago. Gets better with NyQuil and worsens after four hours.

MUSCULOSKELETAL: Denies joint pain, swelling, weakness or limitations in movement. (carpal tunnel bilat). Denies any bone pain. Has no limitation is her normal activities. Low back pain/ache when over does it in a day especially lifting items, started when she was moving. She was doing a lot of heavy lifting. Does not radiate and does not limit her normal activities. Continues to exercise without difficulty. Takes naproxen 250 mg and uses a heating pad when it bothers her. States she’s only needed to take naproxen and use the heating pad a couple of times in the past month. Feels it’s improving.

HEMATOLOGIC: Denies any history anemia or prolonged bleeding. Feels she bruises easily.

LYMPHATICS: Denies noticing any enlarged lymph nodes. Spleen intact.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold intolerance. Continues to have hot flashes and heat intolerance from them. No polyuria or polydipsia.

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

Physical exam:

Vital signs: BP: 130/78 mm hg right arm, sitting. Pulse 82, regular. Respirations 18/min, unlabored. Temperature 97.6 degrees F.

Height: 5’2” Weight: 138 lbs. BMI: 24

Constitutional: C.B. is a 54-year-old alert and oriented well-nourished Caucasian female who articulates clearly, ambulates without difficulty, and is in no apparent distress.

Head/neck: Normocephalic and symmetrical with no masses, lesions, scaling parasites. No tenderness on palpation. No TMJ tenderness, crepitation or ROM limitations noted. Face and all facial features are symmetrical. No swelling or involuntary movements noted. Neck is symmetrical and supple. No limitation in ROM. Trachea midline. No masses, lesions, tenderness, or lymphadenopathy. Thyroid gland nonpalpable and nontender. Jugular veins flat at 45-degree angle. Carotid arteries 2+ and equal bilaterally, no bruits appreciated. (Cervical lymph node tenderness, warm, firm, and mobile to palpation bilaterally).

Eyes: Visual acuity is 20/20 in both eyes without corrective lenses using the Snellen chart. Can read a newspaper 14/14 each eye with corrective lenses. Visual fields full by confrontation. Corneal light reflex is equal in both eyes, no strabismus. EOMs intact with no nystagmus. No ptosis, lid lag, discharge or crusting. Conjunctivae clear. Sclerae white, no redness or lesions noted. Pupils 3 mm bilaterally when resting and 1 mm bilaterally when constricted. PERRLA.

No ophthalmoscope available, but normal finding would be: fundus should be red to dark brown-red, and clear without obstructions. The optic disc creamy yellow-orange, round or oval, distinct margins, and the physiological cup should be a brighter yellow-white. Vessels are equal in all quadrants without crossing defects. No exudates or hemorrhages.

Ears: Ears are equal in size and shape. Skin color is same a facial color, intact, no lumps or lesions. No tenderness of the tragus when pushed forward or the pinna when moved. External ear canal with no redness, swelling or discharge. The tympanic membrane is shiny, pearl gray and translucent. Ear drum is flat. Could hear 6 out of 6 whispered letters bilaterally.

Nose: Symmetrical and midline. No deformities, inflammation, skin lesions and nontender (area under nose and around nares reddened and puffy). Both nares are patent. Nasal septum midline and intact. Nares smooth, pink, and moist bilaterally (appears swollen and bright red with clear drainage). No swelling, discharge, or bleeding. Frontal and maxillary sinuses are nontender.

Mouth/Throat: Lips are pink. Mucus membranes are pink, moist and intact without lesions. Teeth are intact without wearing or discolorations. Gums without bleeding or swelling. Tongue is midline, pink and without swelling. Tongue protrudes at midline, no tremor. No lesions. Palate pink and intact. Uvula is midline and rise midline when says “ahhh”. Pharynx pink. Tonsils 1+ with no exudate noted bilaterally (tonsils 2+, reddened with white patches). + gag reflex with tongue depressor to back of throat. Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion.

Skin: Pinkish tan skin throughout. Freckles (fine flat brown macules) over bridge of nose and over shoulders. No birth marks, or edema. Warm, dry and intact throughout. Tattoo of a rose on left shoulder. (papular rash by left lateral malleus, size of a quarter, non- pruritic) Good skin turgor. Hair normal distribution and texture; no pest inhabitants or lesions noted. Nails are smooth pink and uniform with a normal angle. No signs of clubbing, biting or deformities. Brisk capillary refill. (Skin reddened around tip of the nose and under nasal area) .

Heart: No abnormal pulsations over precordium, no heaves. Apical impulse at the 4^th intercostal space in left midclavicular line, no thrills. Heart sounds regular, S1 and S2 are not diminished or accentuated. No S3 or S4 auscultated. No murmurs auscultated.

Respiratory/Thorax: Normal respiratory effort without use of accessory muscles. AP < transverse diameter. Chest expansion symmetrical. Tactile fremitus equal bilaterally. Lung fields resonant to percussion. Diaphragmatic excursion 4 cm and equal bilaterally. Lung sounds clear bilaterally all lung fields. (Frequent dry cough noted during exam).

Abdomen: Rounded and symmetrical. No bulging or visible masses. Umbilicus is inverted at midline without swelling or discoloration. Skin smooth with no lesions, scars, or striae. Normal bowel sounds over all four quadrants. No bruits noted. Tympany predominates in all quadrants. Liver span 6.5 cm. Abdomen soft/ nontender throughout. No masses or organomegaly noted. No inguinal lymphadenopathy. No CVA tenderness.

Extremities: Color tan-pink. Legs and arms are symmetrical. No redness, cyanosis, lesions, edema or varicosities. No calf tenderness. Radial and brachial pulses + 2 bilaterally. Femoral, popliteal, dorsal pedis, and posterior tibial artery are + 2 bilaterally. No color changes when legs are elevated.

Musculoskeletal: TMJ as assessed under head/neck. Neck- full range of motion without pain or tenderness. All joints symmetrical without swelling, discoloration, or masses. Full active and passive range of motion of all joints. No pain or crepitation. Vertebral column without tenderness, no deformity, or curvature. Full extension, lateral bending and rotation. Muscle strength: able to maintain flexion against resistance and without tenderness or pain.

Neurological: Mental status: Appearance, behavior, speech appropriate. Alert and orientated to person, place, and time. Thoughts coherent. Remote and recent memories intact. Sensory: pinprick, light touch, vibration intact and equal bilaterally. Sterognosis: able to identify a key. Graphesthesia: read number 9 when traced on palm. Motor: no atrophy, weakness, or tremors. No clonus. Gait: Normal, smooth, and rhythmic, able to walk in tandem without balance disturbances. Negative Romberg sign. Cerebellar: Finger-to-nose smoothly intact. Bicep, tricep, brachioradialis, quadriceps and achilles DTR’s +2 equal and bilaterally.

Cranial nerve I- able to identify coffee and peppermint in each nostril individually. Cranial nerve II- see eye exam (confrontation and ophthalmoscope exam). Cranial nerve III, IV, and VI- See eye exam (EOM, pupil reaction). Cranial nerve V- Jaw movement symmetrical, no pain with clenching, and unable to open jaw by pushing down chin. Able to sense cotton on forehead, cheeks, and chin equally and bilaterally. Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion. Cranial nerve VII- face symmetrical with changes in facial expressions and unable to open tightly closed eyes. Cranial nerve VIII- see ear exam (whisper test). Cranial nerve IX and X- see mouth and throat exam (uvula movement and gag reflex). Cranial nerve XI- Sternomastoid and trapezius muscles are equal in size and strength. Able to rotate head against resistance equally and bilaterally.

Diagnostic results: None available

Differential Diagnoses

Acute upper respiratory infection (URI): Is an acute infection typically caused by the human rhinoviruses, respiratory syncytial virus, influenza viruses, coronaviruses and adenoviruses (Passioti, Maggina, Megremis, & Papadopoulos, 2014). The common presenting symptoms are sore throat, nasal congestion, rhinorrhea, sneezing, cough, fever, malaise, and headache (Passioti et al., 2014). There is little variation is presentation among the different viruses making it difficult to diagnosis which virus is responsible for the symptoms (Passioti et al., 2014).
Tonsillitis- bacterial vs. viral: Tonsillitis is an acute inflammation of the tonsils by either a bacterial infection or viral infection (Shepard, 2013). Viral tonsillitis presents with red and swollen tonsils and associated with dysphagia, nasal congestion, fatigue, headache and cough typically present in upper respiratory infections (Shepard, 2013). Bacterial tonsillitis has the same appearance as viral tonsillitis but is also associated with grey/white exudate on visual inspection, fever, painful swallowing, and tender cervical lymph nodes (Shepard, 2013).
Subacute low back pain: Is low back pain that lasts four to twelve weeks after initial strain or injury (Qaseem, Wilt, McLean, & Forciea, 2017). A third of patients will continue to have low back pain up to a year after the initial injury (Qaseem et al., 2017).
Acute respiratory infections are self-limiting and usually resolve on their own in seven to 10 days (Passioti et al., 2014). Nasal swab to determine the viral cause could be done (Passioti et al., 2014). This is not commonly done in my area unless influenza is suspected. Treatment of symptoms is recommended (Passioti et al., 2014). Antihistamines such as diphenhydramine 25 mg every four hours can reduce runny nose and sneezing (Passioti et al., 2014). Decongestants can be used for nasal congestion, but do not offer long term symptom relief (Passioti et al., 2014). Intranasal corticosteroids and antitussives are not recommended for use (Passioti et al., 2014). Acetaminophen 325 mg orally every four to six hours can be used to reduce muscle aches and malaise (Passioti et al., 2014). Education regarding covering mouth when coughing and hand hygiene to reduce passing the virus on to others (Passioti et al., 2014). Return to clinic in four or five days if symptoms not improved.
Tonsillitis: Any sore throat with exudate and increased redness should be cultured with a throat culture (Shepard, 2013). Viral agents are most commonly the causative agent for tonsillitis or any sore throat (Shepard, 2013). With a negative culture, symptomatic management is similar to upper respiratory tract infections, but patients may find relief from throat drops and increasing fluids (Shepard, 2013). If culture comes back positive, then antibiotics would be started. The most common causative agent is Group A beta hemolytic strep (Shepard, 2013). In patients with a Penicillin allergy would be started on Erythromycin or Clarithromycin for five days (Shepard, 2013). I would order Clarithromycin 250 mg orally every 12 hours based on better GI tolerability and less frequent dosing than erythromycin (Edmunds & Mayhew, 2013). Return to clinic is symptoms not improved in four to five days.
Subacute low back pain is typically improved by one month, but may persist up to one year (Qaseem et al., 2017). Recommendations are to remain as active as possible, apply dry heat to the area when needed, and NSAIDS for pain as needed (Qaseem et al., 2017). I would recommend her current self treatment. The low back pain is not limiting her abilities, and is not occurring daily. She finds the heating pain and naproxen to be effective when she needs to use it. Return to the office if the character of the back-pain changes or naproxen is no longer effective.

References

Edmunds, M., & Mayhew, M. (2013). Pharmacology for the primary care provider (4 ed.). St. Louis, MO: Elsevier.

Passioti, M., Maggina, P., Megremis, S., & Papadopoulos, N. (2014). The common cold: Potential for future prevention or cure. Current Allergy and Asthma Reports, 14(413), 1-11. http://dx.doi.org/10.1007/s11882-013-0413-5 Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion.

Qaseem, A., Wilt, T., McLean, R., & Forciea, M. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166, 514-530. http://dx.doi.org/10.7326/M16-2367

Shepard, A. (2013). Assessment and management of acute sore throat. Nurse Prescribing, 11(11), 549-553.

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