Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion

Jul 16, 2017Jul 16 at 7:20pm

Collapse Subdiscussion Sarah Gray

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

Sarah Gray

Jul 17, 2017Jul 17 at 3:16pm

Dr. Lunsford and Classmates

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.

NR509week3soapnote.docx

Jul 19, 2017Jul 19 at 8:18pm

Collapse Subdiscussion Sarah Gray

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

Sarah Gray

Jul 22, 2017Jul 22 at 10:41am

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.

Jul 23, 2017Jul 23 at 8:04pm

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

Jul 21, 2017Jul 21 at 9:09am

Collapse Subdiscussion Lacie Emerine

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

Jul 18, 2017Jul 18 at 8:09am

Collapse Subdiscussion Lacie Emerine

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

Jul 18, 2017Jul 18 at 8:56am

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.

Amanda Russo

Amanda Russo

Jul 18, 2017Jul 18 at 11:16am

Hello Lacie,

I enjoyed reading your SOAP note! I too decided that the patient was suffering from a sinus related cause due to the headache and cough. I chose acute sinusitis. I also stated a complete HEENT would need to be completed. Acute sinusitis was my choice due to the fact that symptoms include “pressure or fullness around the nose, behind of between your eyes, or in your forehead” (Goodman, 2013, p. 837). Other symptoms can include cough, stuffy nose, decreased sense of smell, and possible nasal drainage. I did, however, add an abdominal assessment as well due to the back pain since abdominal issues tend to radiate to other areas.

Reference

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

Jul 19, 2017Jul 19 at 9:06pm

Thanks Lacie,

Please expand on the cardiac and respiratory assessment.

What would you do to manage the current symptoms?

Dr. L

Lacie Emerine

Jul 20, 2017Jul 20 at 3:15pm

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.

Jul 23, 2017Jul 23 at 8:05pm

Thanks for adding these Lacie,

I had two questions on cranial nerves on my board exams. Very important for advanced assessment.

Dr. L

Jul 21, 2017Jul 21 at 11:15am

Hi Lacie,

What physical exam findings would you expect to find with bronchitis and how would you treat this based on current guidelines?

Dr. L

Lacie Emerine

Jul 23, 2017Jul 23 at 8:15pm

Collapse Subdiscussion Amanda Russo

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

Amanda Russo

Jul 18, 2017Jul 18 at 10:58am

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.

Jul 19, 2017Jul 19 at 9:15pm

Hi Amanda. Thanks for the post. What would be your top three differentials if you found RLQ tenderness on your exam?

Dr. L

Amanda Russo

Amanda Russo

Jul 20, 2017Jul 20 at 1:28pm

Collapse Subdiscussion Christine Wood

Hello Dr. L.,

The top three differentials for RLQ tenderness would be appendicitis, bowel obstruction, and Crohn’s. Appendicitis is a common abdominal surgical emergency. It is “inflammation of the vermiform appendix that may lead to an abscess, ileus, peritonitis, or death if untreated” (D’Souza & Nugent, 2016, p. 142). RLQ pain is a common symptom of appendicitis. Colicky abdominal pain is common with bowel obstruction (Jackson & Raiji, 2011). Crohn’s disease is also a common painful inflammatory disease which causes abdominal pain. It would be important to assess the characteristics of the pain. How does the pain feel? Does it hurt only with palpation? Does it hurt anywhere else? B.W. would require a KUB or CT of the abdomen to further investigate this RLQ pain.

References

D’Souza, N., & Nugent, K. (2016). Appendicitis. American Family Physician, 93(2), 142-143.

Jackson, P., & Raiji, M. (2011). Evaluation and management of intestinal obstruction. American Family Physician, 82(2), 159-165.

Jul 18, 2017Jul 18 at 1:20pm

Dr. Lunsford and Class,

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.

Wood.week3.SOAP.docx

Jul 19, 2017Jul 19 at 9:17pm

Hi Christine,

Thanks for the post. What exam findings would you expect with a COPD exacerbation?

Dr. L

Christine Wood

Jul 20, 2017Jul 20 at 7:01am

Collapse Subdiscussion Christine Wood

Dr. Lunsford,

I would expect to find dyspnea (at rest or on exertion) and possibly wheezing on auscultation of the lungs, which may also increase on exertion. Other findings may include pursed-lip breathing and the tripod position.

Rene

Jul 23, 2017Jul 23 at 12:33pm

Collapse Subdiscussion Jessica Hopkins

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.

Rene

Miravetlles, M., Anzueto, A., & Jardim, J. R. (2017). Optimizing bronchodilation in the prevention of COPD exacerbations. Respiratory Research, 181(24). doi:10.1186/s12931-017-0601-2

Week3.Dr.Response.docx

Jessica Hopkins

Jul 23, 2017Jul 23 at 7:03pm

Dear Christine and Dr. Lunsford;

I absolutely agree with you that you would treat the exacerbation as well as doing a thorough history and physical assessment to determine underlying factors of the potential causes of the exacerbation, some lifestyle changes that may be needed to minimize these risks, and also to build a relationship to gain further knowledge of potential deficits of their care that could potentially be avoided.

According to Galloway (2016), we as practitioners need to be screening for chronic obstructive pulmonary disease (COPD) at a much earlier stage in the potential disease process, especially those who have underlying risk factors for it such as chronic lungs problems like asthma, chronic bronchitis, smokers, and those who are over 35 and suffer from frequent breathlessness, frequent episodes of cold or bronchitis, regular sputum production, and wheezing. Studies have been conducted showing proof that approximately 85% of those who get diagnosed with COPD had presented to their pcp for such symptoms as mentioned above often within the 5 years before an actual diagnosis of COPD was made (Galloway, 2016).

Some of the main risk factors of being diagnosed with COPD are smoking, chemical exposures while at work, and infections such as pneumonia and influenza (Galloway, 2016). As practitioners, a great method of prevention of these illnesses that we could offer and strongly suggest would be to receive a yearly influenza vaccine and pneumonia vaccine. Another way we can help our patients is by offering resources and possibly medication interventions in smoking cessation especially those who do suffer from frequent sicknesses and are diagnosed with COPD and continue to smoke. Smoking not only poses a serious risk for a worsening disease process, but also is very dangerous and poses a major safety risk especially those who are oxygen dependent at home. Education and knowledge is key and we as providers mustn’t assume that our patients able to be a part of their ultimate treatment plans.

Jessica

Reference:

Galloway, M. (2016). Minimising exacerbations in early COPD. Practice Nurse, 46(10), 32-36.

Jul 23, 2017Jul 23 at 8:10pm

wms-GOLD-2017-Pocket-Guide.pdf

Jessica,

Excellent point here about screening. I am VERY passionate about this because of my current practice in the palliative care setting. About 50-60% of all end stage patients I am caring for have COPD. It is really interesting to sit down with them and get that thorough history. Really great job here.

Also, for the entire class I would ask that you start familiarizing yourself with the COPD Gold Guidelines. This is essential for management of COPD.

I have attached the most recent guidelines for you to download.

Dr. L

Collapse Subdiscussion Elizabeth Booth

Elizabeth Booth

Jul 18, 2017Jul 18 at 2:47pm

NR509_Week 3_SOAP note.docx

SOAP Note Format

Patient Information:

ASB, 34 year old, Male, Caucasian, Self-pay (no insurance)

CC (chief complaint): headache, back pain, and cough

HPI:

Onset: cough and back pain began 3 months ago, headache and back pain for 2 days after riding a horse that tried to “buck” him off

Location: bilateral pain to forehead, lower back pain above buttocks

Duration: headache and back pain continuous for past 2 days

Characteristics: dull, aching pain with pressure to forehead, mild severity headache, dry cough without pain, back pain mild severity but is sore and “feels tight”

Aggravating Factors: working outside in the heat makes the headache worse, moderate exercise and going from lying to sitting position makes back pain worse, cough gets worse after eating

Relieving Factors: closing eyes and rest makes headache go away, lying flat on his back decreases back pain, cough decreases with bland meals

Treatment: Motrin 400 mg by mouth every 4 hours taken for headache and back pain, no treatment for cough

Current Medications: Motrin 400 mg PO every 4-6 hours for headache and back pain

Allergies: No known drug, environmental, or food allergies.

PMHx: Immunizations up to date. Tetanus vaccine 2016. Influenza vaccine 2016. No major surgeries. No medical problems. Soc Hx: Works as a self-employed horse trainer. Hobbies include hiking and boating. Pt lives with his parents in a ranch-style home. No children. Denies alcohol, tobacco, and drug use. Pt does not wear a helmet when horse-back riding.

Fam Hx:

Maternal grandmother- arthritis, hypertension, depression

Maternal grandfather- hypertension, gastroesophageal reflux disease, spontaneous pneumothorax

Paternal grandmother- unknown

Paternal grandfather- unknown

Mother- anxiety, depression

Father- unknown

ROS:

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

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat: No hearing loss, sneezing, runny nose or sore throat.

SKIN: No rash or itching.

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

RESPIRATORY: No shortness of breath. + dry, non-productive cough

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

GENITOURINARY: No burning with urination.

NEUROLOGICAL: No dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. +headache to bilateral forehead.

MUSCULOSKELETAL: No joint pain or stiffness. + lower back pain

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlarged 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: No history of asthma, hives, eczema or rhinitis.

Physical exam:

VITAL SIGNS: BP 112/62, T: 97.8, HR: 68, RR:16, WT 172, HT 5’11”

CONSTITUTIONAL: Well appearing, well nourished, in no distress. Oriented x 3, normal mood and affect. Ambulating without difficulty.

HEENT:

Head: Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring. Facial features symmetrical and overall unremarkable. No weakness noted. Hair distribution, texture, and quantity overall unremarkable.

Eyes: Visual acuity intact, conjunctiva pink and without excess vascularity. No discharge, excessive tearing, or photophobia. Sclera white, EOM intact, PERRL 4mm, fundi have normal optic discs and vessels. No exudates or hemorrhages.

Ears: External auditory canals clear, TMs translucent and mobile, ossicles normal appearance, hearing intact. No lesions noted to external structures. No tenderness on retraction of pinnae or pressure to tragus. Forced whisper perceived accurately at 5 feet. Weber: midline-no lateralization. Rhinne test: AC > BC.

Nose: No external lesions, mucosa non-inflamed, septum and turbinates normal. Symmetrical without evidence of septal deviation or trauma. Nares patent and turbines intact. Mucosa is pink and without evidence of discharge, exudates, swelling, or congestion. No parasinus tenderness. Sinuses transluminate equally bilaterally.

Mouth: Mucosa pink and moist without lesions to the buccal cavity. Dentition in good repair. Gingivae pink without edema, erythema, or lesions noted. Tongue is midline without fasciculation. No coating or lesion noted. No odor present.

Throat: Oropharynx without erythema, exudates or increased lymphoid tissue noted. Tonsils are present and otherwise unremarkable. Uvula is midline and rises symmetrically. Gag reflex intact. Phonation without hoarseness and otherwise unremarkable.

Neck: Supple with full range of motion. Symmetrical. Trachea midline. Thyroid is not enlarged and is without nodularity. No cervical spine tenderness.

SKIN: No rash. Good turgor. Overall fair without unusual bruising or prominent lesions. Nail beds pink with good capillary refill. Skin warm and dry to touch.

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

RESPIRATORY: Respirations unlabored and even without distress. Vesicular breath sounds heard throughout without adventitious sounds noted. No egophony, whispered pectoriloguy, or bronchophony is noted.

GASTROINTESTINAL: Unremarkable to inspection with normoactive bowel sounds heard in all 4 quadrants. Tympanic percussion noted throughout. No tenderness to palpation. Abdomen is without organomegaly or abdominal masses. No lateral pulsation to aortic region. No CVA tenderness. Negative for Blumberg’s sign, Illiopsoas sign, Murphy’s sign, and Rovsing’s sign.

GENITOURINARY: Exam deferred.

NEUROLOGICAL: Alert and oriented x 3. No mental status deficits noted. Babinski negative. Romberg negative. No motor deficits noted. Cranial nerves intact. Olfactory-Pt able to identify different smell with each nostril separately. Optic-Pt able to read with each eye and both eyes. Oculomotor-PERRLA. Trochlear– Both eyes are able to move as necessary. Trigeminal– +corneal reflexes, sensitive to pain stimuli and distinguish hot from cold. Abducens– both eyes move in coordination. Facial– Pt able to make various facial expressions without difficulty and able to distinguish between different tastes. Vestibuloccochlear– Pt able to hear equally in both ears. Pt able to ambulate in an upright position without losing balance. Glossopharyngeal– + gag reflex and able to swallow without difficulty. Vagus– able to swallow without difficulty. Speech is audible. Accessory– able to shrug shoulders and turn his head from one side to the other without difficulty or pain. Hypoglossal– able to move tongue in different directions.

MUSCULOSKELETAL: Normal gait. Muscle strength 5/5 to all groups. Joints with full range of motion to all planes and without deformities. Spine with full range of motion and curvature normal. No paravertebral tenderness.

HEMATOLOGIC: No bleeding or bruising noted.

LYMPHATICS: No enlarged nodes.

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

Diagnostic results: No past or recent test results available.

In this case scenario, my primary intervention would be to complete a comprehensive neurological exam in order to rule out a mild traumatic brain injury (TBI), otherwise known as a concussion. This patient is complaining of back pain and a headache after riding a bucking horse two days ago. Since a direct impact is not required to cause a TBI, I would still need to rule out an injury to the head that could have been caused by rotational forces being applied to the brain, related to the back and forth motions that were created when the horse attempted to buck the patient off of him. Based on his negative neurological findings, neuroimaging at this time is not warranted but, rather, the patient should be given verbal and written instructions on when to seek further medical care. I would recommend that the patient be monitored at home by a responsible caregiver who also would have the ability to seek medical care for my patient if he starts to show symptoms of a concussion, which could include, but is not limited to, personality changes, confusion, delayed verbal responses, loss of consciousness, increased sleep, blurred vision, dizziness, nausea, and vomiting. My treatment plan would include advising physical rest and Tylenol. I would advise him to discontinue his usage of Motrin to treat his headache and back pain since it could cause further bleeding if he were to develop intracranial bleeding (Scorza, Raleigh, & O’Connor, 2012). I would also take this opportunity to provide education on the importance of wearing a United States Equestrian Federation approved helmet while participating in any equestrian activities, not just riding, to decrease the risk of injury (Lemoine, Tate, & Lacombe, 2017).

Regarding my patient’s complaint of low back pain, my ability to obtain an accurate history and physical exam, especially of the lumbosacral and abdominal region, is paramount in differentiating serious exam findings from benign. This patient has a normal neurologic examination of the lower extremities that assesses strength, sensation, and reflexes so my treatment for nonspecific acute low back pain would be advising the patient to take Tylenol for pain. Since I am also concerned about a possible TBI, I would also advise the patient to stay passively active without aggravating his headache and low back pain, while still avoiding complete bed rest (Casazza, 2012).

Lastly, based on his description of a dry, non-productive cough that is worse after eating, I would diagnose him with gastroesophageal reflux (GERD), where a chronic cough lasting over eight weeks long is indicative of this disease. Treatment would include prescribing him a prokinetic agent like metoclopramide (Reglan), as well as an acid suppressant with a proton pump inhibitor like esomeprazole (Nexium). Patient follow-up will be necessary to ensure that the patient continues to recover without further issues (Mahashur, 2015).

Elizabeth

References

Casazza, B. (2012). Diagnosis and treatment of acute low back pain. American Family Physician, 85(4), 343-350. Retrieved from http://www.aafp.org/afp/2012/0215/p343.html

Lemoine, D., Tate, B., & Lacombe, J. (2017). A retrospective cohort study of traumatic brain injury and usage of protective headgear during equestrian activities. Journal of Trauma Nursing, 24(4), 251-257. doi:10.1097/JTN.0000000000000300

Mahashur, A. (2015). Chronic dry cough: Diagnostic and management approaches. Lung India, 32(1), 44-49. doi:10.4103/0970-2113.148450

Scorza, K., Raleigh, M., & O’Connor, F. (2012). Current concepts in concussion: Evaluation and management. American Family Physician, 85(2), 123-132. Retrieved from http://www.aafp.org/afp/2012/0115/p123.htmlLinks to an external site.

Jul 20, 2017Jul 20 at 7:28pm

Collapse Subdiscussion Elizabeth Booth

Hi Elizabeth,

Thanks for the post! What assessment findings would you expect to find with systolic vs. diastolic heart failure?

Dr. L

Elizabeth Booth

Jul 22, 2017Jul 22 at 6:39pm

NR509_Week 3_instructor response.docx

Dr. Lunsford,

In general terms, diastolic heart failure (left heart failure with preserved ejection fraction) occurs when the heart loses the ability, due to its’ thick and stiff heart muscle, to contract enough to propel blood flow forward, which causes problems with contraction and ejection of blood. Medical conditions such as aortic stenosis, hypertension, mitral regurgitation, and ischemia can cause the heart muscle to become thin and weak. In contrast, systolic heart failure (left heart failure with reduced ejection fraction) occurs when the heart contracts normally but the ventricles are unable to adequately relax and fill with enough blood, due to a thin and weak heart muscle, and less oxygen rich blood is pumped out into the body. This can be caused by mitral stenosis, tamponade, and hypertrophy (Komamura, 2013).

Assessment findings, such as edema, pulmonary rales, and jugular venous distention, are similar in both systolic and diastolic heart failure. However, the presence of a third heart sound (ventricular gallop) and displaced cardiac apex (the apex beat should normally be palpable at the fifth intercostal space and half an inch medial to the left midclavicular line) is usually indicative of systolic heart failure (King, Kingery, & Casey, 2012). How the patient responds to exercise can also indicate whether the patient is experiencing systolic versus diastolic heart failure. In diastolic heart failure, the thick and stiff heart muscle requires more pressure be placed in the left ventricle, in order to maintain cardiac output during exertion. However, the increased pressure can cause stiff lungs or permit fluid to be transported into the alveoli leading to breathlessness. On the other hand, in systolic function, the patient is more likely to report fatigue during exercise. This occurs when the thin and weak heart is unable to adequately increase the stroke volume in response to exercise. Without adequate cardiac output, the muscles used during exercise are unable to be perfused and sends signals to the brain, which the patient interprets as fatigue (Lopez et al., 2012). Echocardiography, however, remains the most widely acceptable method for diagnosing systolic or diastolic heart failure by assessing left ventricular ejection fracture, left ventricular size, wall thickness, valve function, and the pericardium (King et al., 2012).

Elizabeth

References

Lopez, P., Vazquez, J., Campos, A., Bueno, L., Torres, J., & Beiras, A. (2012). The causes, consequences, and treatment of left or right heart failure. Vascular Health and Risk Management, 7, 237-254. doi:10.2147/VHRM.S10669

King, M., Kingery, J., & Casey, B. (2012). Diagnosis and evaluation of heart failure. American Family Physician, 85(12), 1161-1168. Retrieved from http://www.aafp.org/afp/2012/0615/p1161.html

Komamura, K. (2013). Similarities and differences between the pathogenesis and pathophysiology of diastolic and systolic heart failure. Cardiology and Research, 2013, 1-6. doi:10.1155/2013/824135

Jul 23, 2017Jul 23 at 8:13pm

Great job Elizabeth! To prepare for clinicals (which you will definitely see heart failure in your primary care rotations), start familiarizing yourself with the common diuretics and the mechanism of action, class, etc. Some of these include:

Lasix

Bumex

Torsemide (not as widely used)

Bumex

Aldactone

Zaroxolyn

Dr. L

Christine Corbeil

Jul 23, 2017Jul 23 at 4:08pm

Collapse Subdiscussion Jade Balow

Hi Elizabeth,

Great post! I’ve never really associated coughing with gastroesophageal reflux disease (GERD). Rai (2013) documents a large majority of patients with GERD related cough do not have the symptoms of heartburn or acid indigestion. Other symptoms when stomach acid reaches the larynx or pharynx is hoarseness, throat clearing, and vocal cord issues (Rai, 2013). Rai (2013) also documents the cough worsens with supine positioning, and epigastric tenderness may be found on examination. Gladu and Hawkins (2012) recommend treatment with a proton pump inhibitor as you mentioned with esomeprazole with reassessment in 2 weeks for cough elimination.

Thank you,

Christine

Gladu, R., & Hawkins, C. (2012). Combatting the cough that won’t quit. The Journal of Family Practice, 61(2), 88-93.

Rai, S. (2013). Chronic cough. Journal of the Association of Physicians of India, 61, 28-30.

Jade Balow

Jul 18, 2017Jul 18 at 3:35pm

SOAP Note Format

Patient Information:

S.B., 20, F, Caucasian, BlueCross/BlueShield

CC: Patient presents to the clinic with complaints of headache, back pain, and cough

HPI:

Onset: Headache 10 days ago, back pain 1 day ago and cough 4 days ago.

Location: Headache present in the frontal lobes, back pain located in the mid to low back region.

Duration: Headache over the past 10 days with no relief. Back pain began 1 day ago and is intermittently present; cough has been progressive over last 4 days.

Characteristics: Associated with feeling tired, nausea, sensitivity to light and activity.

Aggravating Factors: Bright lit areas, and getting up and down increases back pain.

Relieving Factors: Rest and low lit rooms.

Treatment: Has been taking OTC medication for headache, back pain and cough

Current Medications:

-OTC Midol complete (acetaminophen/caffeine/pyrilamine) PO q6H PRN for menstrual cramping and the headache for the past 4 days.

-Methocarbamol 750 mg tablet PO BID (this was prescribed to her by her dentist for her Jaw pain and tightness 6 months ago.

-OTC Robitussin extended release PO 10 ml oral solution every 12 hours for cough for the past 24 hours.

Allergies: No known drug or food allergies.

PMHx: Immunizations all up to date. Last tetanus shot 6/12/13. No other health history noted.

Soc Hx: Patient is going to nursing school and working a night shift job as a nursing tech. She is also very involved in her sorority as well. Lives at home with mother, father and brother. Likes to play softball and any outdoor activities.

Fam Hx:

Mother- Vitiligo

Father- Hypertension, hyperlipidemia

Brother- Cerebral Palsy, asthma.

ROS:

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

HEENT: Head: Normocephalic, no lumps no lesions no tenderness no trauma. (chronic headache present in the frontal lobe area, exacerbated by bright light/flashing light)

Eyes: No visual loss, blurred vision, double vision or yellow sclerae.
Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN: Skin appears normal for ethnicity. No rash or itching present.

CARDIOVASCULAR: No palpitations or edema present. (Chest tightness with dry cough occasionally, but not constant).

RESPIRATORY: No shortness of breath (cough present. Patient reports persistent dry cough with little to no sputum production. Cough is worse as the day progresses. Sputum when present is white/clear, thin. Patient has no history of smoking or lung disease).

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

GENITOURINARY: No previous pregnancy. Last menstrual period, 06/20/2017 (Some occasional discomfort and burning present with urination).

NEUROLOGICAL: No previous head injury. No dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No previous seizures. No coordination problems, difficulty swallowing or speaking. (dull, constant headache in frontal lobes, exacerbated with light, rates pain 8/10, radiates down into jaw area, causes patient to feel nauseous occasionally).

MUSCULOSKELETAL: No joint pain, stiffness or swelling. No knee pain. No bone pain, ADLs performed with full function. No occupations hazards noted. (Back pain noted to be intermittent, exacerbated with movement/activity, cramping feeling in mid to low back bilaterally).

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlarged 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: No history of asthma, hives, eczema or rhinitis.

Physical exam:

CONSTITUTIONAL: 20 year old female patient presents to the clinic today with complaints of headache, back pain and cough. Patient is alert and oriented and able to provide her own history and presentation. Vital signs: BP 118/62, T: 97.8, HR: 81, RR:17, WT 138, HT 5’6” SpO2 99% room air.

HEENT:

Eyes: Visual acuity intact, conjunctiva pink and without excess vascularity. No discharge, excessive tearing, or photophobia. Sclera white, EOM intact, PERRL 3 mm, fundi have normal optic discs and vessels. No exudates or hemorrhages.

Ears: External auditory canals clear, TMs translucent and mobile, hearing intact. No lesions noted to external structures. No tenderness on retraction of pinnae or pressure to tragus. Forced whisper perceived accurately at 5 feet.

Nose: No external lesions, mucosa non-inflamed, septum and turbinate’s normal. Symmetrical without evidence of septal deviation or trauma. Nares patent and turbines intact. Mucosa is pink and without evidence of discharge, exudates, swelling, or congestion. No Para sinus tenderness.

Mouth: Mucosa pink and moist without lesions. Lips are moist, no cracks or lesions noted. Teeth are intact, not diseased or loose. Tongue is midline and symmetrical with lesions or patches present.

Throat: Trachea is midline, no lymph node enlargement noted. Tonsils are present bilaterally and unremarkable. Gag reflex is intact.

Neck: Head is midline, symmetrical and erect. Accessory muscles are intact and symmetric. Full range of motion is present. Thyroid is no enlarged, no nodularity noted.

SKIN: Skin color is appropriate for ethnicity. Skin is smooth. No rash. Good turgor. Skin is warm, dry and intact. Nail beds are pink, good circulation present. Capillary refill < 2 seconds.

CARDIOVASCULAR: Carotid artery palpated one at a time 2+. Carotid artery auscultated, no bruits noted. Brachial pulse 2+. No JVD present. Radial and pedal pulses 2+ bilaterally. No peripheral edema present. Anterior chest wall is symmetric; Heart tones regular S1 & S2. No thrills, murmurs, clicks or gallops.

RESPIRATORY: Chest wall is symmetrical, thorax is symmetric with downward sloping ribs. Scapulae are symmetrically placed in each hemi thorax. Neck and trapezius muscles are developed normally for pt age. No lesions present. No shortness of breath visible. Bronchial and bronchovesicular lung sounds noted. Tactile fremitus present upon palpation. Resonance heard throughout lung fields. Skin color is consistent with ethnicity (Cough, patient reports sputum to be clear/white, and thin. Expiratory wheeze noted to upper R and L lung fields).

GASTROINTESTINAL: Abdomen is symmetric. Bowel sounds present all quadrants, tender upon palpation to right and left upper quadrants. No mass noted.

GENITOURINARY: External genitalia without lesions. Labia symmetrical and plum, well-formed bilaterally. Vaginal walls pink and moist without lesions or evidence of trauma. (Discomfort occasionally on urination, burning has been present before but not lately according to patient).

NEUROLOGICAL:

Mental Status: Patient is alert and oriented to person, place and time. Speech is appropriate. Recent and remote memory is intact.

Cranial Nerves:

II: Vision 20/20 L eye, 20/20 R eye, peripheral visual fields intact.

III, IV, VI: PERRLA, no ptosis or nystagmus. EOMs intact.

V: Ophthalmic, maxillary and mandibular sensation intact, equal bilaterally. Muscle equally strong bilaterally

VII: Facial muscles intact and symmetric.

VIII: Acoustic nerve intact, whispered words heard bilaterally

IX, X: Voice is smooth and unstrained. Tongue is symmetric, no lesions or abnormal color present. Swallow intact, gag reflex intact, uvula and soft palate rise midline with phonation.

XI: Sternomastoid and trapezium muscles are equal in size bilaterally. Shoulder shrug, head movement equal bilaterally.

XII: Tongue forward thrust is midline, no tremors. Lingual speech of letters L, T, and D are clear and distinct.

Motor: No muscles atrophy present. Muscles size is equal bilaterally. No weakness or tremor present. Muscle strength is equal and strong. Tone is normal. Rapid alternating movements (RAM)- finger – to – nose movement is smooth and accurate. Gait is smooth and coordinated. Patient is able to tandem walk, negative Romberg.

Sensory: Pinprick, light touch, and vibration sensation intact. Kinesthesia intact. Stereognosis- able to identify a key. Graphesthesia- able to identify the number 5.

Reflexes: Normal abdominal, no Babinski sign present. Deep tendon reflexes (DTRs) 2+ bilaterally, No clonus, hyperreflexia or hyporeflexia present.

MUSCULOSKELETAL:

Cervical spine: is in alignment with head and neck. Head is erect. Spinous processes and sternomastoid, trapezius and paravertebral muscles are firm and non-tender and symmetrical.

Shoulders: size and contour are equal bilaterally. No muscular spasms, atrophy, swelling or tenderness noted in shoulders. ROM painless, symmetric and within normal limits.

Elbows: No deformities, redness, or swelling present. No tenderness, nodules or synovial thickening present at the olecranon process. ROM within normal limits. Muscles strength strong and equal bilaterally.

Wrist and Hand: Skin is smooth, no swelling, nodules, lesions or tenderness present. Normal flexion. Wrist and hand are in alignment bilaterally. ROM within normal limits, no limited motions or pain. Muscle strength strong and equal bilaterally. Phalen test -, Tinel sign -.

Hips: No pain upon palpation of the hip joints bilaterally. No crepitation present. ROM within normal limits. Muscles strength strong and equal bilaterally.

Knees: Skin smooth, normal for ethnicity and intact bilaterally. No swelling, pain or tenderness upon palpation of the knee joints bilaterally. Muscle and soft tissue feel solid, smooth, no warmth present, nodularity or tenderness ROM within normal limits. Muscles strength strong and equal bilaterally against resistance. Negative McMurray test.

Ankle and Foot: Ankle and foot are symmetrical and in alignment. Full weight bearing is tolerated. Toes point straight forward and lie flat bilaterally. Skin is smooth and even bilaterally. No joint swelling, tenderness, pain present. ROM within normal limits. Muscles strength strong and equal bilaterally.Able to maintain flexion within all musculoskeletal assessment areas against resistance and without tenderness.

Spine: While standing, patient’s spine is erect, midline, and straight. Knees and feet are aligned forward facing with the trunk. ROM=flexion of 80 degrees, smooth and symmetrical. C-shape curve present. (Back pain expressed like a slight muscle cramp in the lower back region is noted when the patient bends over forward).

HEMATOLOGIC: No bleeding or bruising noted.

LYMPHATICS: No enlarged nodes.

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

Diagnostic results: No past or recent test results available.

Differential Diagnoses:
1. Common Cold

1. Tension headache
2. Nephrolithiasis (kidney stones)
3. Arnold- Chiari formation

The differential diagnosis is ordered from most to least likely for this patient. I would like to obtain a chest x ray on this patient as well as a CBC and BMP. The clinical manifestations and findings of the patient might be indicative of potential common cold. Although the patient does not have rhinorrhea or itchy, watery eyes, she does express some back pain/aches as well as tension headache and low energy and cough. This could be the beginning of a cold kicking in. There is no definitive diagnostic testing regarding diagnosis of the common cold, treatments can include staying hydrated, drinking plenty of water, using an NSAID for aches and pains as well as continuing her use of decongestant. Education regarding getting rest and hydration is important here as well as education regarding hand washing since she works in the long term care setting at a nursing home as a night shift tech (DeWitt, 2016). I would want to follow back up with this patient if her symptoms persist.
Another potential diagnosis is chronic tension-type headache (TTH) due to stress of school, work and social activities. These types of headaches can last 30 minutes to 7 days and are characterized by bilateral pressure, tightening or pulsating pain mild to moderate intensity (Schub & Boling, 2016). Photophobia and phonophobia occur with this type of headache. The patient stated that she had sensitivity to light when her headache is bad. Background regarding how often she has this type of headache, how long does it last, and how it improves with what medication she has been trying over the counter are all going to be a critical part in helping categorize this headache and diagnosis. I would want to education the patient on how she can log the headache and symptoms so we can look at it together if the symptoms persist. (Schub & Boling, 2016). Risk factors for TTH include stress, anxiety, depression, panic disorder, OCD, changes in sleep regimen and certain medications. S.B meets several of the requirements and a more in depth conversation about how she handles her stress and anxiety might be helpful. Stress reducing habits can be taught about here as well such as taking a hot bath, physical therapy, massage, acupuncture, lying down with a warm or cool cloth over the forehead for nonpharmacological methods (Schub & Boling, 2016).
Nephrolithiasis is another potential diagnosis to rule out for this patient. It would be a good idea to go a little bit further in depth with her history questions and ask the patient about her urinary habits, certain foods and drinks that she might consuming. A 24-hour urine collection could help rule out the presence of lithogenic substance in the urine. Diagnosis of nephrolithiasis is based on clinical presentation and diagnostic findings (Pfau, Eckardt, & Knauf, 2015). A rare but potential last diagnosis could be Arnold-Chiari type 1 malformation (CMI), which is downward displacement of the cerebellar tonsils through the foramen magnum into the upper cervical spinal canal (Fischbein et al., 2015). Clinical presentations of CMI are related to the direct compression of the brain stem and spinal cord to CSF disturbances. CMI typically begins in young adults and includes headache, visual disturbances, neuro-otological complaints, and other cranial nerve dysfunction. Although the patient does not yet exhibit neuro-otological complaints, it could be in the back of our mind to rule out asking more questions about these specific areas as they might not be showing symptoms all the time, they could be over looked (Fischbein et al., 2015).

References:

Carson-DeWitt, R. (2016). Common Cold. Health Library: Evidence-Based Information,

Fischbein, R., Saling, J., Marty, P., Kropp, D., Meeker, J., Amerine, J., & Chyatte, M. (2015). Patient-reported Chiari malformation type I symptoms and diagnostic experiences: A report from the national Conquer Chiari Patient Registry database. Neurological Sciences, 36(9), 1617-1624. doi:10.1007/s10072-015-2219-9

Pfau, A., Eckardt, K., & Knauf, F. (2015). [Diagnosis and treatment of nephrolithiasis. What is established?]. Der Internist, 56(12), 1361-1368. doi:10.1007/s00108-015-3758-0

Schub, T. B., & Boling, B. C. (2016). Headaches, tension-type. CINAHL Nursing Guide

Jul 20, 2017Jul 20 at 7:32pm

Hi Jade! Can you describe assessment findings for systolic murmurs (and list what murmurs are systolic)?

Dr. L

Jade Balow

Jade Balow

Jul 21, 2017Jul 21 at 11:44am

Dr. Lunsford,

A murmur is a “gentle, blowing, swooshing sound” that is produced by turbulent blood flow and blood flow that is experiencing collision in some way (Jarvis, 2016). Blood viscosity and velocity are key factors in the presence of murmurs as well as valvular and structural heart diseases (Miller, 2016). Murmurs are either systolic or diastolic in origin, depending on when the murmur is occurring. Accurate diagnosis of a murmur includes being able to note several areas of detail regarding the murmur. These include: timing, loudness, pitch, pattern, quality, location, radiation and posture (Jarvis, 2016). A murmur that occurs in systole may be innocent or indicative of a problem, but a diastolic murmur is always indicative of heart disease. It is very important to keep an open mind about the murmur you hear, and take step by step process to identify key characteristics in order to accurately diagnose the murmur. When you hear an abnormal heart sound, do not forget that a very important aspect of the patient assessment is the patient history. A thorough history is first and foremost of importance when assessing a murmur (Miller, 2016).

First, when you hear a murmur, identify if it is heard in systole or diastole. In order to do this, you can listen to the murmur with your stethoscope (where you hear the murmur the loudest) and simultaneously palpate the carotid pulse only on one side. If the murmur you hear times up with the pulse of the carotid artery this indicates a systolic murmur. Second, identify where you hear the murmur the loudest; this will help indicate where the murmur is originating. The loudness of the murmur is noted in order to “grade” the murmur, based on a scale out of 6 options of grade. Grade 1 is the lowest and grade 6 represents the loudest (Jarvis, 2016). A very common systolic murmur is mitral valve prolapse murmur; this murmur presents an audible “click,” and may be the easiest one to identify. Other systolic murmurs include: mitral regurgitation murmur, physiological murmur and aortic stenosis murmur.

A change in patient position can expose a murmur as well. When a patient lies on the left side, an S3, S4, and murmur of mitral stenosis may be heard that was not otherwise noted. Leaning forward and sitting upright on the exam table is a good position for the patient to be in for the NP to assess for a soft diastolic murmur of aortic or pulmonic regurgitation. Diagnostic test such as an ECG and echocardiogram will establish an accurate diagnosis of innocent murmur (Jarvis, 2016).

References:

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

Miller, B. A. (2016). A 31-year-old female with a systolic heart murmur. Medicine Morning Report: Beyond the Pearls E-Book, 277.

Kara Flatt

Kara Flatt

Jul 23, 2017Jul 23 at 8:06pm

Collapse Subdiscussion Christine Corbeil

Jade-

Thank you so much for your post! I was interested to read the variety of differential diagnosis’ you used. As nurse practitioners it is important that we look for a variety of issues, however, I think it is equally important that we be able to hone in to what may be the culprit instead of casting a large net and seeing what we get. While I could identify with common cold and a tension headache, I am having trouble with your diagnosis of kidney stones and Chiari malformation. I know that kidney stones can be characterized by back pain, but not so much with headache or a cough. Could you explain to me your reasoning for picking this diagnosis?

-Kara

Jul 18, 2017Jul 18 at 5:44pm

Dr. Lunsford and class,

Patient Information:

C.B., 54, female, Caucasian

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.

Jul 20, 2017Jul 20 at 7:34pm

Collapse Subdiscussion Christine Corbeil

Hi Christine! Can you discuss what you would find on your assessment if you auscultated a diastolic murmur? And what murmurs are diastolic?

Dr. L

Jul 23, 2017Jul 23 at 10:02am

Hi Dr. Lunsford,

Diastolic murmurs are auscultated at the beginning of the S2 sound or immediately after the S2 sound and end prior to the beginning of S1 (Premkumar, 2016). All murmurs are caused by increased turbulence of blood flow through the valves and the duration and intensity of the murmur is determined by the amount of pressure generated in the heart chambers (Premkumar, 2016). The main way of diagnosing a heart murmur is by transthoracic echocardiography (Premkumar, 2016). The main diastolic murmurs are left sided valve disease of mitral stenosis, aortic regurgitation, and right sided valve diseases of stenosis of tricuspid stenosis and pulmonic regurgitation (Jarvis, 2016).

Mitral stenosis is most commonly caused by childhood rheumatic fever (Premkumar, 2016). It can also be caused by calcification of the leaflets over time (Nisimur et al., 2014). Typically, asymptomatic initially (Vahanian et al., 2012) and others will have some degree of shortness of breath (Premkumar, 2016). The murmur is low-pitched rumbling heard best at the apex in the left lateral position with an opening snap (Premkumar, 2016). There may be a right ventricular heave (Premkumar, 2016). Nishimur et al. (2014) document there will not be any significant physical examination findings.

Aortic regurgitation is caused by rheumatic heart disease, bicuspid aortic valve, endocarditis, and aortic root dilation (Premkumar, 2016). The back flow of blood into the left ventricle caused left ventricular enlargement (Premkumar, 2016). Clinical presentation is shortness of breath with activity, chest pain and pulmonary edema (Premkumar, 2016). S3 heart sound is present and a diastolic blowing decrescendo murmur is noted on exam that is loudest at the left sternal border (Premkumar, 2016). A water-hammer pulse and wide pulse pressures will be noted on physical exam (Premkumar, 2016). Apical impulse will be felt to the left and will feel shorter than normal (Jarvis, 2016).

Right sided valve disease is primarily asymptomatic (Coffey, Rayner, Newton, & Prendergast, 2014). Symptoms may be reduced exercise tolerance and fatigue (Coffey et al., 2014). As the pressures increase in the right atrium and right ventricle, there is enlargement and dilation of both chambers leading to symptoms of right sided heart failure (Coffey et al., 2014). Increased jugular venous pressure, hepatomegaly, ascites, and peripheral edema (Coffey et al., 2014). Tricuspid stenosis is mostly caused by rheumatic fever and occurs with mitral valve stenosis (Coffey et al., 2014). Auscultation of a diastolic rumble at the lower parasternal border is rare due to the low-pressure gradient of the right side of the heart (Coffey et al., 2014). Pulmonary regurgitation is commonly seen in the normal population in trivial to small amounts (Coffey et al., 2014). It’s mostly seen in patients who have had a repair of the valve for pulmonary stenosis or Tetralogy of Fallot repair (Coffey et al., 2014). A diastolic decrescendo murmur is sometimes heard in the second left intercostal parasternal space which is only heard in the setting of pulmonary hypertension (Coffey et al., 2014). There may be a right sided lift with the right ventricle is overloaded (Coffey et al., 2014). Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion

References

Jarvis, C. (2016). Physical Examination and Health Assessment, 7e (7 ed.). St. Louis, MO: Elsevier.

Nishimura, R., Otto, C., Bonow, R., Carabello, B., Erwin, J., Guyton, R., … Thomas, J. (2014). 2014 AHA/ACC guidelines for the management of patients with valvular heart disease. Circulation, 1-235.

Premkumar, P. (2016). Utility of echocardiogram in the evaluation of heart murmurs. Medical Clinics of North America, 100, 991-1001. http://dx.doi.org/10.1016/j.mcna.2016.04.005

Vahanian, A., Alfieri, O., Andreotti, F., Antunes, M., Esquivias, G., Baumgartner, H., … Zembala, M. (2012). Guidelines on the management of valvular heart disease. European Heart Journal, 33, 2451-2496. http://dx.doi.org/10.1093/eurheartj/ehs109 Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion

Jul 23, 2017Jul 23 at 8:18pm

https://www.fhea.com/content.aspx?p=certificationcols/mnemonics.htmLinks to an external site.

This is great Christine! I remember in FNP school I did not feel confident in my abilities to identify and classify murmurs, but once you get out into clinicals and start hearing them yourself, it is so exciting. I had several questions on murmurs on my boards. It is very important to be able to differentiate systolic vs. diastolic. I included this link below that has a mnemonic that I used to memorize these and apply them to my practice. There are also some other pearls as well.

Dr. L

Collapse Subdiscussion Sarah Gray

Sarah Gray

Jul 22, 2017Jul 22 at 2:13pm

Christine

Thanks for your post! I came across this article discussing pertussis and how it can be a missed diagnosis for patients with a cough lasting longer than the traditional 10 days of an URI and thought it was interesting. Pertussis can present similar to a upper respiratory infection during the initial one to two weeks. This period is call the Catarrhal stage and patients present with malaise, rhinorrhea, sneezing, lacrimation and mild cough. The second phase is termed paroxysmal stage, in which severe coughing spells occur, most commonly during exhalation. In patients previously immunized, symptoms are less severe. Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion. Pertussis should be suspected if a cough is present for more than three weeks even without the classic paroxysmal cough. Nasopharyngeal aspirate or swabbing for cultures is the best choice for diagnosis and to test for antimicrobial sensitivity (Kline, Lewis, Smith, Tracy, & Moerschel, 2013).

Reference

Kline, J. M., Lewis, W. D., Smith, E. A., Tracy, L. R., & Moerschel, S. K. (2013). Pertussis: A reemerging infection. American Family Physician, 88(8), 507-514.

Christine Corbeil

Jul 23, 2017Jul 23 at 3:09pm

Collapse Subdiscussion Jessica Hopkins

Hi Sarah,

Thank you for your reply! I’ve been surprised regarding the different causes of persistent coughs. Coughs that last three to eight weeks are considered subacute coughs, and a chronic cough is one that lasts greater than eight weeks (Gladu & Hawkins, 2012). Upper airway cough syndrome, asthma, gastroesophageal reflux, postinfectious cough, and pertussis (Gladu & Hawkins, 2012). Postinfectious cough was a new one for me when I was diagnosed with it in February after recovering from Influenza. It’s a cough that lingers three to eight weeks after an upper respiratory infection related to continued inflammation of the airway (Gladu & Hawkins, 2012). Like pertussis it can paroxysmal in nature and pertussis should be ruled out with a nasal swab (Gladu & Hawkins, 2012). There is a lot of information on coughs to sift through to come up with an accurate diagnosis. Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion

Thank you,

Christine

Gladu, R. & Hawkins, C. (2012). Combatting the cough that won’t quit. The Journal of Family Practice, 61(2), 88-93.

Jessica Hopkins

Jul 18, 2017Jul 18 at 6:39pm

Collapse Subdiscussion Jade Balow

Dear Class and Dr. Lunsford;

Patient Information:

CM, 59, Male, Caucasion, Medicare part A and B

Vitals: BP-148/88, HR 82, R 20, T 99.1F, sp02 93% RA, pain 5/10

CC cough, headache, and back pain

HPI: include all the information regarding the CC using the OLDCART format. If the CC was “Unintentional weight loss”, the OLDCART for the HPI might look like the following example:

Onset: 14 days

Location: upper back, head

Duration: for the last 2 weeks

Characteristics:increased fatigue, poor appetite, cough with phlegm, throbbing headache worse with coughing, chest wall aching worse with cough

Aggravating Factors: coughing fits, smoking, poor sleep at night

Relieving Factors: cough syrup (Nyquil), rest, Motrin, Norco 5/325mg as needed

Treatment: Nyquil, Motrin 600mg, Norco 5/325mg every 6 hours as needed

Current Medications:

Motrin 600mg every 6 hours as needed for mild pain and headache

Norco 5/325mg every 6 hours as needed (usually only takes one at bedtime) moderate to severe pain- has been using for 3 years since back surgery

Nyquil 2 tsp at bedtime for the last 2 weeks

Simvastatin 40mg at bedtime for high cholesterol- been using for 3 years

Hydrochlorathiazide (HCTZ) 25mg daily for high blood pressure- been using for 3 years

PeptoBismol OTC as needed for upset stomach

Benadryl 25mg as needed for bee stings

Allergies: nkda, mild allergy to bee stings

PMHx: hypertension, high cholesterol, alcoholism. Surgeries- L5 lumbar fusion with spinal column widening due to stenosis and nerve pain, fractured ribs x 3 this year. CM is up-to-date on tetanus within the last 5 years, denies yearly influenza vaccine, has received the pneumonia vaccine last year due to frequent colds (3-4 per year)

Soc Hx: retired mechanic of 37 years, married, enjoys renovating his cottage home, smokes 1-2 ppd (40 years), drinks 12 cans of beer daily (40 years), nevers drinks and drives, wears seatbelt everytime, has functioning smoke detectors all throughout the home

Fam Hx: father- polio, MS (deceased at 42 years old)

Mother- emphysema, high cholesterol, alcoholic (deceased massive heart attack at 70 years old)

Brother- colon cancer (deceased at 51 years old)

Grandparents- unknown (all deceased)

ROS:

CONSTITUTIONAL: No weight loss, positive for fever, chills, and 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.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, positive for chest wall discomfort with cough. No palpitations or edema.

RESPIRATORY: positive for mild shortness of breath with exertion, productive cough and greenish-colored sputum.

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

GENITOURINARY: denies burning on urination. Pregnancy not applicable.

NEUROLOGICAL: positive for mild, pounding headache that worsens with cough, denies dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion.

MUSCULOSKELETAL: positive for mild muscle aches and chronic lower back pain in the L5 region, positive for upper thoracic back pain that worsens with cough, denies joint pain or stiffness.

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlarged 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: No history of asthma, hives, eczema or rhinitis.

Physical exam: for the purpose of this week’s discussion the heart, lungs, peripheral vascular system, musculoskeletal, and neurologic with cranial nerve physical assessment are done

Heart: No cardiomegaly or thrills noted on exam, regular rate and rhythm, no murmur or gallop heard on auscultation, palpation of the carotid artery demonstrates a smooth, rapid upstroke with a normal stroke of 2+ and equal bilaterally, auscultation of the carotid artery shows no bruit, apical pulse not visible, vibrations are regular and even, pulsations equal, no dyspnea or heart discomfort noted, S1 and S2 auscultations are normal and distinct with loudest sound at the apex of the heart, no additional extra heart sounds heard on auscultation, absent for rubs

Peripheral vascular system: Inspection of bilateral arms for symmetry, size, edema present, color, ulcerations, hair distribution, and texture of skin noted with no abnormal findings, bilateral symmetry of upper extremities, no edema present, color is dark tan with macules (freckles) noted bilaterally, skin is warm and dry to the touch, no ulcerations, or scaring noted bilaterally, fingers warm and pinkish tan in nature, capillary refill is less than 3 seconds bilaterally, radial pulses present bilaterally and strong and resilient, brachial pulses equal and strong bilaterally, bilateral leg exam done as well to test the vascular system with even distribution of hair noted, some scaring of the right knee noted due to a bicycle accident as a child, no ulcerations noted, toes warm and dry and equal bilaterally, palpation of femoral artery, popliteal, posterior tibial, and dorsalis pedis pulses equal and strong bilaterally, no varicose veins visible on exam, no redness or discoloration of the skin over veins noted, Homan’s sign represents no pain or tenderness

Lungs: Inspection of the posterior chest for shape and configuration are straight, thorax is symmetric, skins color and condition is smooth and even, negative for any discoloration or scars, no cyanosis or pallor noted, no lesions noted, palpation of the posterior chest is symmetric with expansion, no areas of tenderness noted on exam, percussion of the posterior chest in the lung fields demonstrates normal resonance, the diaphragmatic excursion is equal bilaterally measuring approximately 5 cm, auscultation of the breath sounds demonstrates bronchial, bonchovescicular, and vesicular sounds heard in the lung fields with mild crackles heard on expiration, inspection of the anterior chest is symmetrical for shape with a costal angle of 90 degrees, the skin color and condition is free of cyanosis and pallor, quality of respirations is effortless, regular, and even, chest expansion normal with inspiration, breathing pattern is regular and normal, percussion of the lungs is resonant with dullness noted over the liver region of the chest, auscultation is vesicular and clear with some mild crackles noted in the lower bases of the lung fields on exam

Musculoskeletal: Normal gait and station, no asymmetry noted on inspection, no crepitation, tenderness, masses, some decreased range of motion noted in the lower L5 region with bending down, no instability, abnormal strength or tone in the head, neck, pelvis, or extremities, mild tenderness noted in the thoracic region (t6-t12) on palpation, inspection and palpation of the spine feels firm with no muscle spasm or tenderness, shoulders demonstrate equal size and contour bilaterally with no redness or deformities noted, no scoliosis noted, no ROM abnormalities noted except for the lower back region due to his past surgical history

Neurologic: mental status is alert and oriented, assessment of the cranial nerves done and intact.

CN II: optic nerve intact, visual acuity normal, normal blinks, able to close and open eyes normally

CN III, IV, VI: oculomotor, trochlear, and abducens nerves intact, pupils PERRLA, gaze normal, no nystagmus noted, able to raise eyelids equal bilaterally, able to move eyes inward and out equally with ease

CN V: trigeminal nerve intact. Able to grind teeth and make chewing motion when asked

CN VII: facial normal and able to move all muscles of face equally

CN VIII: acoustic nerve intact. Hearing intact

CN IX: glossopharyngeal nerve intact, able to swallow when asked, able to move tongue in and out with no difficulty

CN XI: spinal intact. Normal movement of trapezius and sternomastoid muscles

CNXII: hypoglossal nerve intact. Able to stick tongue out when asked

Muscle strength, tone, and size even and equal throughout, gait steady, negative Romberg test, coordinated movements throughout all muscle groups, senses intact in all extremities with no decrease in sensation noted, reflexes intact at 2+ in all extremities, gcs is 15.

According to Jarvis (2016) a physical assessment of the systems coordinates together and although each system is done individually, we must as practitioners keep in mind that many of our assessments play off of each other very well and we must be cognizant of our patients and their responses both physically on exam and in the subjective sense Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion. I’ve found by performing the initial health history speaks in large volumes of what the patient perceives as medical problems such as pain and what we actually find on the physical exam portion. It is very interesting and exciting while performing these assessments to think at a more advanced and critical level than how we just reviewed the systems as registered nurses. I work in an emergency department and we practice focused assessments often forgetting the person as a whole.

According to Fennessey (2016) nearly 210,000 and 440,000 patients die annually due to improper and inadequate physical assessments which is preventable in nature. Sentinel events occur due to these poor assessments leading to death. Assessment is a systematic and ongoing collection of patient data that is utilized to be able to provide safe, high-quality care to those in need and we as practitioners must perform thorough physical assessments to continuously achieve positive patient outcomes (Fennessey, 2016). It is our duty to practice, practice, practice to become more knowledgeable and proficient in our skills and techniques for clinical practice.

Reference:

Fennessey, A. (2016). The Relationship of burnout, work environment, and knowledge to self-reported performance of physical assessment by registered nurses. MEDSURG Nursing, 25(5), 346-350.

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

Jade Balow

Jul 19, 2017Jul 19 at 1:14am

Collapse Subdiscussion Jessica Hopkins

Jessica Hopkins,

Great post this week! You did a really great job at organizing your post, clearing addressing each of the required sections. One of the hardest parts of this week for me was organizing this post to make sure that all the appropriate areas where fully addressed. This was the most detailed SOAP we have done thus far, making it more challenging for me! Overall, we are all getting the hang of this. What I enjoyed most about your post was the summary paragraph regarding the overall physical assessment of the symptoms. Providing one chief complaint of a cough has taken everyone’s SOAP note in a different direction. It is so neat to read through and see how everyone’s patient this week can be so similar and also so very different, yet we all have the same chief complaints presented to us. We are all able to use these posts and learn from one another as we all have different patients and backgrounds in assessment. Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion. It can be so intimidating that all of the body systems are individually complex and yet are all interrelated to one another. As we learn to assess and notice different things in our careers we will see many patterns and develop a skill set for this, but right now as fresh as it all is, you make a great point addressing the complexity of this in your post. I, too, work in an area where a focused assessment is key. Not to undermine the fact that the overall picture is also important. In the ICU it seems that we can get so focused in on certain parts of the assessment that we don’t realize that the type of assessment I do right not is nothing like the type of assessment I am preparing for with FNP program. I think that it must be very beneficial to you being an ER nurse and seeing the patients that initially come in-is like staring from ground zero-much like we will as NP. In the ICU I tend to already know what my focuses are on based on the hard work of the ED admitting MD’s that diagnose the patient and order many of the initial exam workups. Our assessment should be seen as whole, that is made up of the parts so we can inspect both, which, like you mentioned, just takes practice. The process of our assessments should be organized and well-formed so that we can provide accuracy and continuity with our approach to assessment as the NP (Konopasek, Norcini, & Krupat, 2016). I am enjoying this journey so far, I hope you are too!

Reference:
Konopasek, L., Norcini, J., & Krupat, E. (2016). Focusing on the formative: Building an assessment system aimed at student growth and development. Academic Medicine, 91(11), 1492-1497.

-Jade B.

Jessica Hopkins

Jul 19, 2017Jul 19 at 1:36pm

Thank you Jade!

I appreciate your kind words and encouragement. Not sure if you feel the same, but often our ICU’s tend to dislike the nurses in the ED. It is very hard to manage a critically ill patient while many are still coming in to be treated for other emergent situations. I give much credit to the ICU nurses as they are the advocate for the critically ill patient and your assessment skills are vital in their treatment. I don’t know if I could be an ICU full-time. I do enjoy when the patients come into our emergency department from the ground up and our goal is to stabilize them to move them to a more suitable treatment area to receive the highest quality of care much like you!

According to Simone (2016) the need and demand for nurse practitioners in the critical care settings has increased tremendously and with your advanced knowledge and skills you are obtaining within your master’s program, this will hopefully allow you to do this if you chose this route as you have an upper hand on all of the ins and outs of the critical care area. The roles have evolved for NP’s in the ICU and with the proper knowledge and skill background you are currently working on along with an appropriate ICU orientation in the new role of NP in a critical care area you would be such a huge asset to the treatment plan and care of those in need of such services. With our advanced knowledge of assessment skills we are obtaining in this program and the knowledge you already have in your ICU practice, you would prove to be such a value to the practitioners of the critical care team (Simone, 2016). Collaboration between you and the physicians would greatly increase positive patient outcomes in a critical care setting.

Reference:

Simone, S. (2016). Integrating Nurse Practitioners Into Intensive Care Units. Critical Care Nurse, 36(6), 59-69. doi:10.4037/ccn2016360

Melissa Chick

Jul 23, 2017Jul 23 at 5:38pm

Jessica,

Thank you for your post!! I mean that whole heartedly. I have personally been struggling on how to get the full assessment every week. Your post provides the ROS and the assessment in detail only for the week’s specific assignment. You have shown a light on a tough topic for me, I really appreciate the clarification. Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion This will allow me to provide more details. You quoted Jarvis (2016) by stating “physical assessment of the systems coordinates together and although each system is done individually, we must as practitioners keep in mind that many of our assessments play off of each other very well and we must be cognizant of our patients and their responses both physically on exam and in the subjective sense”. In this week’s reading it gave a great example to prove your point. When assessing cough, we would ask for details like duration, frequency, type, discharge, color (Jarvis, 2016). The reasoning for this is in sputum production, it can be pulmonary in origin but we know that other systems can also play a part. Sputum production, especially with hemoptysis, can occur with mitral stenosis. This is why the assessment of the heart with auscultation will aid in helping rule out or find the source. According to (Tally & O’Connor, 2014) once the physical assessment is done the diagnosis should be discussed with the patient in order of probability. It was stated that diagnostic errors are caused from breakdown in the success of the clinical encounter (Tally & O’Connor, 2014). How I perceived this is, if the patient comes in for a specific complaint and has given you the provider a sign of said complaint, and your diagnosis does not explain or directly related to said complaint, then the patient will not believe they have been taken care of appropriately. Therefore, if you suspect something like discussed above, a cough may be the result of a heart problem and not a simple respiratory infection. This information may need to be discussed in more detail. Better patient education needs to be given so that our patients believe we are taking care of their complaints. Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion.

Talley, N., O’Connor, S. (2014). Clinical examination: A systematic guide to physical diagnosis (7^th ed.). Australia: Elsevier.

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

Kara Flatt

Kara Flatt

Jul 18, 2017Jul 18 at 8:04pm

Collapse Subdiscussion Taura Collins-Smith

Professor and class: Below you will find my week 3 SOAP Note using the chief complaints of headache, back pain, and cough. -Kara

Week 3: SOAP Note (Subjective and Objective Portions Only)

Patient Information:

K.F. 50 y/o female, Caucasian. Has Health Alliance PPO Insurance provided by her employer, a local health department.

CC: “headache, back pain, and cough”

HPI: Onset: 1 week ago

Location: Generalized

Duration: Progressively getting worse over the last 7 days.

Characteristics: Associated with poor appetite and generalized malaise

Aggravating Factors: Activity

Relieving Factors: Rest, fluids.

Treatment: Self-care only. Rest, fluids, OTC medications.

Current Medications: Lisinopil 10mg PO daily; Cymbalta 60mg PO daily; Xanax 0.25mg PO q 6hrs prn anxiety; Tylenol 500-1000mg PO q 4-6hrs prn pain/fever; Motrin 600mg PO q 6-8hrs prn pain/fever.

Allergies: PCN-urticarial rash

PMHx: Hypertension, migraine headaches, anxiety, fibromyalgia. Tonsilectomy as a child. G2P2.; All childhood vaccines UTD, last TDAP 2008; last pap smear 02/2016; last dental exam 05/2017 (no carries); does monthly self-breast exams.

Soc Hx: Works full time as a RN/Director of Nurses at a local health department. Has 2 biological daughters and an adopted son, all of whom are grown and live within a respectable distance of her. Lives with her husband in a rural area, where she owns chickens, a cat, and a dog. States there are weapons in the form of firearms, in the house but they are secure in a locked vault and away from their children. Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion Reports she always wears a seatbelt when driving and does not ride motorcycles. Does own a boat and wears a lifejacket on all occasions. Does not drink alcohol or us tobacco products of any kind. Denies drug use. States she walks about 1-2 miles at least 4 times a week. Reports one sexual partner over her entire lifetime. Premenopausal.

Fam Hx: Mom-hypertension, anxiety, depression, migraine headache, still living; Dad- multiple myeloma, GERD, irritable bowel syndrome. Brother-Chron’s disease.

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. (Abnormal: headache).

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. (Abnormal: productive cough, green sputum. Dyspneic on exertion).

GASTROINTESTINAL: Poor appetite. No nausea, vomiting or diarrhea. No abdominal pain or blood. Last BM yesterday 07/018/2017 soft, formed, brown.

GENITOURINARY: No dysuria, frequency, urgency, retention, or blood. Last menstrual period, 07/08/2017.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. (Abnormal: pressure to generalized head).

MUSCULOSKELETAL: No muscle pain, back pain, joint pain or stiffness. (Abnormal: c/o back pain around ribs region that is reproducible and worse with deep breathing and coughing).

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety (Abnormal: Anxiety. Depression. Denies suicidal/homicidal ideations. No previous psychiatric hospitalizations.)

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

ALLERGIES: No history of asthma, hives, eczema or rhinitis (Abnormal: PCN-urticarial rash).

Vital signs: Temp 99.4⁰F (37.4⁰C). BP 126/62 mm Hg. Pulse 72 bpm (sitting), regular rhythm. Resp 22/min. Pulse ox 96% on room air, at rest.

Physical Exam:

General: Appears stated age. Well-developed/nourished.

HEENT: Tympanic membranes pearly gray w/ landmarks visible and intact; no discharge; mucosa pink without lesions; tonsil 1+ without exudate; no lymphadenopathy. (Abnormal: sinus congestion/pressure).

Skin: Pink, warm, dry. Good skin turgor. No rashes, vesicles or other abnormal findings.

Respiratory: Breath sounds clear in all fields; no adventitious sounds. Regular rate and rhythm, no accessory muscle use. (Abnormal: slight insp/exp wheezes to right lower lobe).

Cardiovascular: Regular rate (72 bpm) and rhythm when sitting, S1 and S2 are not accentuated or diminished, no extra sounds. All pulses present, 2+ and equal bilaterally. Carotids 2+ with no carotid bruit.

Abdomen: Bowel sounds active in all quadrants. Abdomen soft, non-tender to palpate. No enlargement of liver or spleen.

Diagnostic results: None available.

In summary, our patient has been suffering from a cough, headache, and back pain, progressively getting worse over the past week. She reports a productive cough with green sputum and increased dyspnea on exertion. The pain in her back is located around the right side of her ribs and is reproducible and worsens with coughing or deep breathing. On physical assessment, we have found that she also has a low-grade temperature and wheezes can be heard in her right lower lung bases. She is also slightly tachypneic. For these reasons and more I believe the best course of action would be to do a 2-view chest x-ray, as well as a basic CBC, CMP, and possible blood cultures. I am anticipating her chest x-ray to show a right lower lobe consolidation, or pneumonia. If this is the case I would treat this patient with Levaquin 750mg PO daily x 5 days. “A high-dose (750 mg), short-course (5 days) of once-daily levofloxacin has been approved for use in the USA in the treatment of CAP, as well as acute bacterial sinusitis” (Norredin & Elkhatib, 2010). We could also provide this patient with a metered dose, aerosol Albuterol inhaler: 180 mg, 2 puffs inhaled PO q 4-6 hrs as needed for bronchospasms or shortness of breath. This should not exceed 12 inhalations in 24 hours. Our patient has no known respiratory issues or other health issues that would complicate her treatment. I believe the suspected pneumonia is the cause for the pain she reports in her back, as well as the headache that she is experiencing. We should plan to follow up with her after her antibiotics are completed to make sure she is feeling better. If at any time her symptoms progress or get worse she should be instructed to go to the closest ER for evaluation and treatment.

-Kara

References

Norredin, A., & Elkhatib, W. (2010). Levoflaxicin in the treatment of community-acquired pneumonia. Expert review of anti-infective therapy, 505-514. Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion.

Taura Collins-Smith

Jul 18, 2017Jul 18 at 8:16pm

Patient Information:

E.H., 41, Caucasian, UHC

CC “ headache, backache and cough”

Onset: 2 months ago

Location: headache frontal area; backache lower back

Duration: headache ; backache ; cough-all intermittently during day and night

Characteristics: headache throbbing; backache dull, non-radiating; cough nonproductive, hacky

Aggravating Factors: headache staring at computer and loud noises; backache standing or sitting for long periods; cough lying down makes it worse

Relieving Factors: headache resting, silence; backache lying down; cough cough drops, sitting up Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion.

Treatment: headache & backache Tylenol Arthritis 650mg (OTC); cough OTC cough drops and Robitussin OTC

PMH

- Major Childhood Illnesses-Chickenpox, Impetigo
- Major Adult Illnesses-Influenza 2015
- Surgeries- Cesarean section x’s 3, tonsillectomy age 15
- Hospitalizations-child birth, no other overnight stays
- Immunizations-Last Tetanus 2015, flu vaccination-refused
- Allergies-No food, environmental, or medication allergies

- - Medications-Tylenol Arthritis 650mg 1 PO prn, Robitussin OTC PO prn, Claritin 10mg OTC PO prn, and Women’s daily multivitamin
  - Family History
- Parents-both living, mother with HTN; father with non-alcoholic cirrhosis
- Siblings-One sister, obese but no other major medical conditions

Social History

- Living situation-lives in one story home with spouse
- Children-three children
- Employment-unemployed by choice

Habits

- Tobacco-none
- ETOH-socially approximately 1-2 times per month
- Illegal Drug Use-none

ROS

CONSTITUTIONAL: No fever, no weight loss, no weakness or fatigue

HEENT: Head: (complaint of a frontal headache), no head injury, denies dizziness, no congestion, syncope or vertigo. EYES: wears glasses, last eye exam 11/2016, no visual loss, no eye pain, no blurred or double vision. Ears: Denies hearing loss, earache, tinnitus or vertigo. Nose: no discharge, no sneezing, no stuffy nose, no epistaxis. Throat: no difficulty swallowing, no sore throat.

RESPIRATORY: No SOB, no dyspnea, (complaint of occasional cough)

CARDIOVASCULAR: No palpitations, no chest pain, no edema

NEUROLOGICAL: (has headache), no dizziness, syncope, seizure, tremors, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control

MUSCULOSKELETAL: No joint stiffness, weakness or swelling, (acute low back pain)

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea GENITOURINARY: No burning on urination, no increase in frequency or urgency, last menses 7/05,

PHYSICAL EXAM- 5’5’’, 135 lbs, BMI 22.5, BP 116/68, HR 80, Temp 98.7, RR 18

CONSTITUTIONAL: Appears to be well nourished, dressed appropriately, no apparent distress noted, gait normal

HEENT: Head: Complaint of an occasional headache, head is normocephalic, no lesions, lumps, scaling, parasites, or tenderness, face is symmetric, no weakness, no involuntary movement. Eyes: R: 20/20, L: 20/20-1, Both 20/15 Visual field full by confrontation. EOMs intact, no nystagmus, no ptosis, lid lag, discharge, or crusting. Cornel light reflex symmetric, no strabismus noted. Conjunctivae clear, sclera white, redness, Pupils 3mm resting, 2mm constricted, and + bilaterally. PERRLA. Ears: Pinna with no masses or lesions, scaling, discharge, or tenderness to palpation. Canals clear. Tympanic membrane: pearly gray landmarks intact, no perforation, cone of light present. Whispered words heard bilaterally. Nose: No deformities or tenderness, to palpation. Nares patent. Mucosa pink, no lesions. Septum midline, no perforation. No sinus tenderness. Mouth & Throat: mucosa and gingivae pink and moist, no lesions to buccal mucosa, soft or hard palate, no bleeding. Teeth are white, straight, evenly spaced, clean and free from debris or decay. Gums looks pink, margins at the teeth are tight and well-defined. Tongue is pink and even, saliva present, symmetric, protrudes midline. Tonsils pink, grade 2.

NEUROLOGIC

Cranial nerves:

I-Olfactory able to identify an odor with each nostril, II- optic nerve, Snellen Eye Chart vision is R: 20/20, L: 20/20-1, Both 20/15 Visual field full by confrontation. Corneal light reflex symmetric bilaterally, conjunctiva clear, sclera white, Optic fundus visualized. Cranial nerve III- pupils are centrally placed in the iris and equal in size bilaterally. PERRLA. Cranial nerve IV-clenches and releases jaw, able to feel cotton sensation test on forehead, cheeks, and chin. Cranial nerve V- Trigeminal nerve: Muscles are equally strong on both sides, intact touch sensation to ophthalmic, maxillary& mandibular. Cranial nerve VI Abducens– moves eyes laterally as directed. VII-facial nerve– mobility and facial symmetry when smiling, frowning, eye close tightly, show teeth and puff cheeks. VIII- Acoustic(vestibulocochlear) nerve: hears normal conversation with a whispered voice. IX & X- Glossopharyngeal and Vagus nerves. Uvula and soft palate rise in the midline, tonsillar moved medially. XI- Spinal Accessory Nerve: sternomastoid and trapezius are equal sizes and equally strong. XII-hypoglossal nerve: no wasting or tremor to the tongue, forward thrust to midline, speech is clear and distinct. The neuro-ophthalmology examination is crucial in the assessment of patients with the complaint of a simple headache. By examining the visual acuity, pupils, motility, and fundus, key clues can be discovered and possibly unveil the potential primary and/or secondary cause of a patient’s headache (Friedman & Digre, 2013). This exam is key in the evaluation of headaches and is often overlooked by providers. Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion

MUSCULOSKELETAL

Joints with normal alignment and size, no mass, or deformity noted. All joints noted to have normal temperature. Full ROM with some resistance, temporomandibular joint protrudes without deviation, no crepitus, snapping, of instability noted. Temporalis and masseter muscles are the same size, firmness and strength. Cervical spine is straight and head erect. Head and neck aligned, sternomastoid, trapezius, and paravertebral muscle are firm, no muscle spasms or tenderness. Flexion with full resistance, no pain noted. Bilateral shoulders with equal bony landmarks, normal size and contour, with no pain, redness, muscular atrophy, deformity, heat or swelling. Pyramid –shaped axilla palpated no mass or adenopathy present. Full range of motion present with no crepitation noted. Elbow: tissue and fat pad feel fairly solid. No heat, swelling, tenderness, consistency or nodule noted in the area of the olecranon bursa, feels fairly solid. Elbow with full ROM. Wrist and hand: fingers lie straight in the same axis as the forearm, no swelling or redness, deformity, or nodules are present bilaterally. Skin is smooth and knuckle wrinkles present, no swelling or lesions, bogginess nodules or tenderness noted bilaterally. Full ROM noted bilaterally. Phalen test completed- no numbness, or burning reported. Tinel sign (-) completed no burning or tingling noted. Lower extremity: normal ROM and 5/5 strength in all extremities, no joint enlargement or tenderness; no clubbing, cyanosis, petechiae, or nodes of digits and nails. Hip joints symmetric as well as iliac crests, gluteals folds, and equally sized buttocks noted. Equal leg lengths and functional hip motion assess during gait assessment. Hip flexion WNL. Lower legs extend in the same axis as the thigh. No swelling or warmth noted around patella joint. No abnormal swelling noted around the prepaterllar bursa or suprapatellar bursa. Muscles and soft tissues feel solid and smooth, with no warmth, tenderness, or thickening noted. No atrophy noted in quadriceps bilaterally. ROM, flexion and extension WNL bilaterally. Muscle strength 5/5 in both knees. Ankle and Foot aligned properly. Feet aligned with long axis of lower legs. Weight bearing falls in the middle of the foot. Both feel with a longitudinal arch. The toes point straight forward and lie flat. Ankles (malleoli) are smooth with even coloring and no lesions. No calluses or bursal reactions noted bilaterally. ROM WNL in ankles and all toes. Muscle strength 5/5. Spine is straight as evidenced by equal horizontal positions of the shoulders, scapulae, iliac crests, and gluteal folds. Spinous processes are straight and non-tender. Flexion 90 degrees with smoothness and symmetry of movement. No lumbar curvature noted. Tenderness in lumbosacral area, dull pain reported upon examination and palpation, exacerbates when changing positions for the examination. No Costovertebral Angle Tenderness.

CARDIOPULMONARY:

Carotid arteries palpated individually with a smooth contour and normal strength noted bilaterally. Anterior chest with even color and hair distribution. Apical pulse palpable in the 4^th medial intercostal space. Normal amplitude and duration noted. Aortic, Pulmonic, Tricuspid, and Mitral Valves auscultated, normal sinus rhythm at 80 beats per minute. S1 and S2 are normal. No edema noted bilaterally. Capillary refill noted at 1 second. No scars on hands and arms. Radial pulses palpable, regular rhythm with 2+ force. Epitrochlear lymph nodes are not palpable. Modified Allen test performed and adequate circulation noted by palmar blush and return to normal color of the hands within 5 seconds. Bilateral legs with symmetry, even color, even temperature, and normal hair distribution. No skin lesions or ulcers noted. No tenderness noted upon palpation. Inguinal lymph nodes are small, moveable and non-tender. Peripheral arteries, femoral arteries, popliteal, dorsalis pedis, and posterior tibial pulses are palpable, with no abnormalities noted. No edema noted bilaterally. Lungs auscultated in all lung fields anteriorly and posteriorly and noted to be clear with no adventitious sounds. Resonance sounds noted to percussion. Occasional non-productive cough noted during the exam. Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion. No lesions, scars, or wounds noted on chest. Thoracic cage is symmetric and the scapulae are placed symmetrically in each hemithorax. Skin color is normal and even over the entire body. No cyanosis or pallor present. Symmetric expansion of chest noted from posterior and anterior testing.

GASTROINTESTINAL: Abdomen is flat and round, smooth and symmetric, skin smooth with no lesions, bowel sounds present in all four quadrants, tympany predominates in all quadrants, abdomen soft to touch, dullness heard over liver and spleen. No bruits heard over abdominal aorta, renal arteries, or iliac arteries. Liver, kidney and spleen non-palpable; no tenderness on palpation, no organomegaly, no mass, tenderness, Umbilicus midline and inverted. Liver is in the RUQ.

Reference

Friedman, D. I., & Digre, K.B. (2013). Headache medicine meets neuro-ophthalmology: exam techniques and challenging cases. Headache, 53(4), 703-716. doi: 10.1111/head.12058

Jul 22, 2017Jul 22 at 7:36pm

Thanks Taura,

Be sure to post a summary of your case with your primary care recommendations/interventions based on the current guidelines and evidence. Let me know if you have any questions.

Dr. L

Taura Collins-Smith

Taura Collins-Smith

Jul 23, 2017Jul 23 at 6:12pm

Collapse Subdiscussion Melissa Chick

Hi Dr Lunsford, I guess I am a little confused. I thought that we only needed the S AND O. Thanks

Jul 18, 2017Jul 18 at 8:52pm

Collapse Subdiscussion Taura Collins-Smith

SOAP Note

Patient Information:

A.B., Age: 40, Sex: female, Race: Caucasian, Insurance: Arkansas BCBS

CC: Patient complains of headache, back pain, and cough

Onset: 1 Week

Location: generalized headache, lower back pain, and cough

Duration: started a week ago, cough is persistent, back pain and headache are constant and have been present all week

Characteristics: pain is worse after being still in the lower back (sleeping, sitting too long) cough is nagging

Aggravating Factors: No difference with eating but movement is uncomfortable. Cough worse in the mornings.

Relieving Factors: OTC cough suppressant has helped a little, OTC Aleve helps minimally with headache and back pain Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion.

Treatment: OTC Aleve, OTC Guaifenesin 200mg q6h.

Current Medications: OTC Aleve, OTC Guaifenesin 200mg q6h, multiple vitamin.

Allergies: Penicillin and Sulfa drugs.

PMHx: Surgical history includes C-section 2000. Last PCP visit and annual physical exam April 2017 at Mercy Primary Care. Influenza vaccine: not current, never gets flu shot, and Tetanus immunization: was 2015. Reports no major childhood illnesses. Reports no illnesses as an adult. Hospitalized for UTI during pregnancy in 2000. Patient has a sister with no medical problems.

Soc Hx: Patient is a second-grade teacher, married with two daughters. Currently lives with husband and both daughters, never a tobacco user, never used illegal drugs, and occasional alcohol use 1 x month. Always wears his seatbelt.

Fam Hx: Patient’s father has diabetes insulin dependent, high blood pressure, hx of cellulitis, obesity. Patient’s mother has hx of breast cancer, double mastectomy 2009.

ROS:

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

HEENT: Eyes: 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: No shortness of breath, cough is present, no sputum.

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

GENITOURINARY: No burning on urination, no sores or lesions, no discharge or hernia. Multipara. Last menstrual period, 06/25/2017.

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

MUSCULOSKELETAL: No muscle pain, back pain present in lower back, no joint pain, but stiffness is present.

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression, report feeling anxious sometimes.

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

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

Physical exam: The patient posture is erect with no involuntary movements, appearance is appropriate for season and setting. Patient is awake, alert, and oriented. Patient is articulate and converses appropriately.

Vitals: BP 96/54, P 72, R 17, T 98.6

Skin: pink, dry, normal turgor

Normal in appearance, texture, and temperature

HEENT:

Head is normo-cephalic, no evidence of tenderness or trauma, pupils equally round, reactive to light and accommodation, sclera and conjunctiva normal. Pinnae is normal no tenderness, tympanic membranes and external auditory canals normal. Nose is straight with no masses, patent bilaterally. Nasal mucosa normal. No tenderness on frontal or maxillary sinuses. Oral pharynx is normal without erythema or exudate. Tongue and gums are normal.

Neck:

Supple with full range of motion, no neck vein distention or nodes detected in cervical or supraclavicular areas. Trachea is midline and thyroid gland is normal without masses. Carotid artery upstroke is normal bilaterally without bruits.

Chest:

Normal anterior-posterior diameter, symmetric excursion bilaterally, normal tactile fremitus bilaterally, lungs are clear to auscultation and percussion bilaterally. No heaves, thrills, or murmurs present. Apical pulse at 5^thICS at MCL, S1 and S2 are not diminished or accentuated.

Abdomen:

The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all 4 quadrants. No masses or splenomegaly no hepatomegaly. No palpable nodes in the axillary or inguinal areas.

Musculoskeletal:

Temporomandibular joint: no slipping or crepitation. Neck: full ROM, no pain, vertebral column: no tenderness, no deformity or curvature, full extension, lateral bending, rotation. Arms symmetric, extremities have full ROM, no pain, no crepitation. Muscle strength: patient able to maintain flexion against resistance and without tenderness.

Neurological:

Mental status: appearance behavior, speech are appropriate. A&O x 3. Cranial nerves I-XII are normal. Motor and sensory examination of the upper and lower extremities is normal. Gait and cerebellar function are also normal. Reflexes are normal and symmetrical bilaterally in both extremities.

In assessment of pain there are several mnemonics that can help. One that I found during research is called VINDICATE. This mnemonic is aimed at determining the etiology of the pain (Morgenstern, 2012). Pain can be considered a disease itself, but it is almost always a comorbidity. If the underlying pathological process is found and treated, the management of pain can be decline. The mnemonic is:

Virus- An infectious process that maybe viral, bacterial, or fungal.

Inflammation- Such as vasculopathies, neuropathies, and arthropathy.

Neoplasm- Tumors, metastases, and other cancer related conditions.

Degenerative- Pathology such as spinal and bone disorders.

Idiopathic- Ischemia, hypoxemia, neural hyperexcitability, and claudication.

Congenital- Metabolism and/or genetic diseases that cause aberrant pain and sensory processing.

Autoimmune- Antigen/antibody reactions, cellular changes, protein metabolism

Trauma- Tissue destruction from an accident, injury, or chemical exposure.

Endocrine- Abnormal hormone levels, glucose metabolism, and electrolyte variations.

(Morgenstern, 2012)

This mnemonic may help us as providers in narrowing down the source of pain so that errors or misdiagnosis do not occur. According to (Morgenstern, 2012) many errors happen due to medical biases. The use of mnemonics like this can aid in reducing biases or patient harm. The article also discussed how as novices we are more susceptible to biases so utilizing the simple techniques may help us in our futures (Morgenstern, 2012)

Morgenstern, B. (2012). Guidebook for Clerkship Directors: Fourth Edition. Alliance for Clinical Education. Retrieved from: https://books.google.com/books?hl=en&lr=&id=_uhaBAAAQBAJ&oi=fnd&pg=PA125&dq=why+use+Vindicate+mnemonic+&ots=wSSg5K41Ge&sig=m4aE_Ewd3qNaGj_d8TEuwgx2Fw0#v=onepage&q&f=falseLinks to an external site.

I attached in a word document also since I believe this messed up my APA format.

Melissa

Taura Collins-Smith

Jul 21, 2017Jul 21 at 8:41am

Hi Melissa, as I was reading through some of the discussions I came across your post and found the mnemonic VINDICATE very intriguing. I decided to do a little research to learn more about it and actually ended up finding another VINDICATE mnemonic used in a patient undergoing testing for chronic cervicogenic headaches for three years. In this case report, the author suggested using VINDICATE to exclude all red flags and possible underlying etiologies of pain (Vascular, Inflammatory, Neoplastic, Degenerative, Infectious, Connective tissue disorders, Autoimmune disorders, Trauma, Endocrinopathies) before performing the joint block for this patient’s disorder (Shantanu, 2013). Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion.

The pneumonic that you used is similar in many ways. I noticed that there are many correlations between the two VINDICATE mnemonics. For example, both of the initial I(s) represent inflammation; both N(s) represent cancer or neoplasm; both D(s) represent degenerative disease; both A(s) represent autoimmune disease, both T(s) represent trauma; and both E(s) represent the endocrine system. Therefore the V, second I, and the C are the only letters that don’t reference the same system when comparing the two. I attempted to find additional articles but had no luck. Your article better explains how to apply the mnemonic to practice, whereas my article was very vague. Thank you for enlightening us on this helpful tidbit that we as future practitioners can use in our upcoming practice when assessing our patient’s pain.

Reference

Shantanu, M. P., (2013). Lateral atlanto-axial joint block for cervical headache. Indian Journal of Pain, (27)2, 103-107. doi: 10.4103/0970-5333.119346

Melissa Chick

Jul 23, 2017Jul 23 at 7:56pm

Taura,

I really liked the idea behind the mnemonic also. When in a hard to diagnose situation something like this that guides us to rule out sources of the problem will help us to avoid diagnostic errors. Personally as a novice I would like as many tools available to me to allow my patient to have the best possible care. I also find it interesting how many of the letters may stand for something else. This might be a mnemonic that can be used in many different areas of the body systems.

Jul 22, 2017Jul 22 at 7:37pm

Hi Melissa,

What would you do for this patient?

Dr. L

Melissa Chick

Jul 23, 2017Jul 23 at 7:49pm

Dr. L

My recommendation for this patient would include further investigation into chief complaint, and possible environmental factors that may be associated with complaints. With this patient having a normal physical examination I would proceed with lab work such as CBC, BMP, and urinalysis. Many inspiratory muscles like the diaphragm can be related to low back pain so this may be associated with the persistent cough. I would also recommend chest x-ray. The patient may have environmental allergies producing the cough, which may also lead to the headache, and low back pain. Specific questions on allergens needs to be asked regarding exposure to: dust mites, pet allergens, mold, indoor pollutants; smoke, combustion, wood or plant fuels, biologic agents, airborne pollutants, humidity, etc (Peden & Reed, 2010). Also, further investigation into history of recurrent respiratory infections, nighttime cough, exercise intolerance, wheezing, and exacerbations caused by viral illness (Peden & Reed, 2010).

Peden, D., & Reed, C. (2010). Environmental and occupational allergies. Journal of Allergy and Clinical Immunology, S2; 150-160.

Catherine Orakpo

Catherine Orakpo

Jul 23, 2017Jul 23 at 7:20pm

Collapse Subdiscussion Catherine Orakpo

Hello Mellisa,

I totally agree with you about using the mnemonics to help reduce patient harm. The “VINDICATE” mnemonic appears to have covered most major question that a healthcare provider will ask to determine a state of illness in a client. Healthcare providers are constantly discovering what an asset mnemonics have become to patient assessment in terms of aiding memory in remembering in orderly method without leaving important details out during assessment. These mnemonics help with problem solving. During the era of ABC mnemonic which implied Airway Breathing & Circulation this was effectively used to teach basic life support foundations as cited by (Yeoh, 2013). Keeping Airway open was important in other to prevent increased partial pressure of carbon dioxide, as it provides for effective ventilation as cited by (Connolly et al., 2012). These Mnemonics are quite helpful especially the “VINDICATE” mnemonic that covers different areas during assessment and will be likely to detect state of illness wherever it exists. Great post!!

References

Connolly E.S., & Rabinstein A.A., & Carhuapoma J.R., & Derdeyn C.P., & Dion J., & Higashida R.T., & Vespa P. (2012). Guidelines for the management of aneurysmal subarachnoid hemmorrhage: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 43, 1711 – 37. 10.1161/STR.0b013e3182587839

Yeoh M. (2013, November). The effectiveness of musical mnemonics in teaching biology: Kreb cycle. Conference Proceedings–5th International Conferenc e on Science and Mathematics Education, Penang, Malaysia.

Catherine Orakpo

Jul 18, 2017Jul 18 at 11:53pm

Hello Dr Lunsford & classmates,

SOAP Note

K.C is a 27 year old African American female, Insurance Blue Cross Blue Shield.
CC (chief complaint) Unbearable headache that radiates to the neck and back as well as cough that is worse at night for the past 2 days”.

OBJECTIVE: Crucial Signs: Weight 177 lbs., Height 5’5 inches, Temperature 99.4 orally, Pulse 76, Respiration 20, B/P 118/70.

HPI
Onset: 2 days ago
Location: Generalized pain in the head
Duration: Continuous head pain
Characteristics: Headache Pulsates, severely intense and prohibits daily activities.

Aggravated by walking stairs, movement of any sort including routine activities. Sensitivity to light noted.

Relieving Factors: Warm compress, Motrin or Tylenol

Treatment: Motrin and Tylenol can treat mild forms of headache Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion.

Allergies: NKDA

Patients Medical History

Random migraine attacks, past surgical history appendectomy 2 years ago, random cough, wheezing and shortness of breath. Experiences low back pain especially after sitting in a spot for prolonged time.

Last PCP visit and annual exam 5 months ago.

Flu shot: current

Family history:

Father: Alive and active in the work force

Mother: Alive and have random migraine headaches

Siblings: Random migraine attacks.

Social History:

KC has close relationship with family especially parents and siblings, feels safe at home environment. Client works as a computer analyst in a computer firm. Hobbies include movies, outdoor activities. Patient denies smoking and drinking

ROS:

CONSTITUTIONAL: No weight loss, severe headache, back pain and cough present

HEENT:

Head: scalp dry but not scaly.

Eyes: patient is using reading contact lens. Last eye exam 2 months ago & WNL. No visual loss, blurred vision, double vision or yellow sclera noted.

Ears: No hearing loss or drainage present, denies hearing changes, tinnitus and vertigo.

Nose: Small drainage noted in the nasal cavity.

Throat: soreness from frequent coughing.

SKIN: Warm, dry, normal turgor, no rash, denies itching

Neck-denies firmness, swelling, or torment

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

RESPIRATORY: denies shortness of breath with regular activities, such as climbing stairs, walking for 20 min of time, coughing present.

GASTROINTESTINAL: no anorexia, nausea, vomiting or diarrhea; no abdominal pain or blood in stool. No abnormality detected when palpated, bowel sound present in 4 quadrants.

GENITOURINARY: patient denies signs and symptoms of UTI, denies hesitancy, urgency, burning, no complaints reported.

NEUROLOGICAL: Excruciating headache present, patient denies dizziness, vertigo, tingling, loss of sensation. No change in bowel or bladder control.

MUSCULOSKELETAL: Patient complains of back pain which rates 4/10 on a pain scale Patient takes acetaminophen or ibuprofen as needed for pain.

HEMATOLOGIC: No anemia, bleeding or bruising noted. CBC pending.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: patient has no history of depression & has strong family support

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

Migraine (784.0) is a chronic neurovascular disorder that causes recurring headaches and disturbances in the perception of pain, light, and sound as cited by (Chawla, 2016). Migraine was previously believed to be caused by cerebral arterial vasoconstriction and rebound dilation, migraine is now thought to be a neurogenic process that causes secondary vascular changes that affect cerebral perfusion. Evidence has shown that genetic predisposition to migraine can be primarily inherited from the mother. Migraine often begins during childhood or adolescence and recurs throughout adulthood and it can be triggered by environmental and biologic stimuli such as stress, menstruation, vasodilators, insufficient or excessive sleep, bright lights, caffeine, alcohol, and food containing nitrates, monosodium glutamate and tyramine- or tryptophan-rich foods (e.g., ripe cheeses, red wine, chocolate). Clinical manifestation includes throbbing, pounding, or pulsating pain that is usually hemi-cranial and lasts 4–72 hours as cited by (Chawla, 2016). Additional clinical manifestations include nausea, vomiting, anorexia, fatigue, increased sensitivity to light and/or sound, numbness, tingling, and weakness and others might experience aura (i.e., neurologic disturbances, including flashing lights, blind spots, tunnel vision, and “seeing stars” that develop over a period of 5–20 minutes and resolve within 1 hour).

Physical Exam:

KC has quiet demeanor with clear and proper discourse. Head standard cephalic, denies trauma, no hematomas, or delicacy to palpation Neck supple with full ROM. Eyes-PERRLA, conjunctiva clear without redness. Visual fields full to showdown. EOM’s full, no ptosis. Optic circles sharp without papilledema, macula in place. Facial nerves functional. Hearing in place client responds to whispered words, External ears without injury. Auricle, tragus, a mastoid contender to palpation Ear channel and tympanic layer pictured are functional and without lesion. Choke reflex and tongue development in place and full. No lymphadenopathy. Moves all furthest points 5/5 quality Coordination in place with a finger to nose testing Sensation in place to stick prick and touch all through. Reflexes 2+ all through, with plantar reactions down going Romberg testing negative. Client owned stressful work schedule and environment. Immunization current, (last tetanus shot 2/25/2011), recent flu illness and still coughing. Never had surgical procedure. A diagnostic workup headache history includes age of onset of headaches; duration of complaint; frequency and duration of each headache; site, quality, and time of onset; associated phenomena; and aggravating and relieving factors. Physical examination, including neurologic examination, is typically normal. Some patients experience substantial burden from their migraines. The Migraine Disability Assessment Scale (MIDAS) is a five-item questionnaire that is used in practice to help healthcare providers.

Treatment: Rizatriptan can be used to treat migraine as well as evaluate patients understanding of medication and make determination whether education needs is required. Other products used in the treatment of migraine are Salicylates, ibuprofen, almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitripta.

It is also important to educate patients that although migraine cannot be cured but that symptoms can usually be managed with appropriate drug therapy.

Healthcare provider will educate patient about prevention and management of migraine as well as encourage patient to keep a headache diary to identify triggers.

Neurologist consult may be recommended.

Non-pharmacology: Patient can lie down in a dark, quiet room when a migraine occurs or place a cold cloth over the eyes.

Eating regularly scheduled meals is recommended as well as maintaining good fluid intake to avoid dehydration.

Muscle relaxation, meditation, acupuncture, massage or biofeedback training can help to reduce stress.

Pharmacology: In severe symptoms administration of these medications will be beneficial rizatriptan Tablets: 5, 10 mg 5 mg q2h not to exceed 30 mg daily. Motrin 800mg TID

Sumatriptan Tablets: 25, 50, 100 mg 25, 50, 100 mg q2h and not to exceed 200 mg daily. Motrin 800 mg TID, aspirin and Tylenol 600 mg QID and not to exceed 2400 mg daily. This can be used to treat the mild to moderate form of migraine.

Patient will be encouraged to seek emergency medical attention for new or worsening symptoms and to notify the treating physician if migraines change in pattern, frequency, or intensity.

Cervico/Disco-genic pain (M.54.5) is usually worse in positions that involve prolonged sitting, especially in sitting positions with a protruded head posture or prolonged flexion. Bending positions also provoke cervicogenic pain. These positions can predispose KC to this differential diagnosis because of the type of work she does for a living especially sitting for too long at a time and analyzing data in a computer. Frequent changes of position provide relief. However, in cases of severe acute pain, a still position may be most comfortable. Pain worse upon awakening is probably related to using an unsuitable pillow or having adopted an inappropriate posture while sleeping.

Treatment: Early referral to Physical Therapy can be very helpful. There are basic measures that have relieved back pain such as proper positioning in bed. Pharmacotherapy is the most common treatment for Low Back Pain as cited by (Goertz, 2016). Treatments with NSAIDs, gentle exercise, and maintenance of activity has proving effective. Patients may also find some acute relief lying on the floor supine with their lower legs and feet resting on a cushioned chair seat. When patient is not responding to treatment epidural glucocorticoid injection (e.g., with methylprednisolone) is a reasonable consideration for temporary relief. This can be administered by a certified nurse anesthetist under fluoroscopic guidance, a needle is inserted and advanced into the epidural space allowing injection of anesthetic and glucocorticosteroids to be administered. The use of topical anesthetic (e.g., lidocaine) helps to determine proper needle placement, immediate pain relief indicates proper positioning, but a worsening of radicular pain during the procedure is a sign of needle misplacement.

Bronchitis (J40): can be defined as lower respiratory tract infection, especially in patients who present with a productive cough. The cough reflex removes large particles from the lower airways, and ciliated epithelium and mucus in the bronchial tree capture particles too small to be removed by coughing. Clinical manifestation includes cough due to mucous production and irritation of airways, wheezing due to inflammation within the airways. Differential diagnosis for cough can be extensive, including common and uncommon disorders as cited by (Weinberger, 2014).

Work up will start with differentiating lower respiratory tract infection from the other causes of cough and from upper respiratory infection. Good physical exam is recommended.CAT Scan pending.

Treatment: Suppression is not encouraged in patients with acute cough because the cough reflex remains an important defense mechanism. In most studies, cough resolves in 1 week regardless of treatment, and persistence of cough in 2 weeks was not unusual. Healthy patients with acute bronchitis should be treated with conservative measures for cough and counseled about the natural history of the disease. Expectorants such as guaifenesin may be helpful to some patients in loosening the sputum, although they have not been proven to make a significant difference in outcome. Prescribed Mucinex 600-1200 mg po q12h; maximum dose 2400 mg/day.

References

Chawla, J. (2016, April 19). Migraine headache. Medscape. Retrieved April 25, 2016, from http://emedicine.medscape.com/article/1142556-overview (RV)

Goertz, M., Thorson, D., Bonsell, J., Bonte, B., Campbell, R., Haake, B., … Timming, R. (2012). Adult acute and subacute low back pain. Institute for Clinical Systems Improvement. Retrieved November 8, 2016, from https://www.icsi.org/_asset/bjvqrj/LBP.pdf (G)

Weinberger M, Fischer A. Differential diagnosis of chronic cough in children. Allergy Asthma Proc 2014; 35: 95–103.

Catherine Orakpo

Catherine Orakpo

Jul 20, 2017Jul 20 at 8:27pm

Hello Dr Lunsford & classmates,

(Omitted data from previous submission)

THE MENTAL STATUS EXAMINATION

KC appears hygienic and well groomed, oriented x3 language is not slurred or abnormal. Good insight and affect noted. Cognitive skill intact.

HEENT

Inspect the face and no swelling noted, facial symmetry

Palpated for sinus tenderness and noted facial grimacing, client acknowledged moderate pain in the frontal and temporal lobes.

Inspected the neck and Palpated neck, lymph nodes not palpable. Auscultate bilateral carotid pulse.

NEUROLOGICAL EXAM:

- - I: olfactory nerve intact, client able to smell.
  - II: Vision 20/40 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 3mm present, palpebral fissures equal bilaterally.
  - V: Sensation intact bilaterally throughout face and equal jaw strength and movement.
  - VII: facial muscles intact and symmetric.
  - VIII: whispered words heard bilaterally
  - IX, X: swallowing intact with positive gag reflex, uvula and soft palate rises midline. Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion
  - XI: Able to shrug shoulder, move head, equally bilaterally.
  - XII: tongue midline, able to stick tongue out, no tremors noted and speech clear.

Christine Wood

Jul 23, 2017Jul 23 at 12:59pm

Catherine,

I am happy to read your SOAP note, which offers non-pharmacologic treatments for resolution of the patient’s complaints. In my own practice, I hope to provide my patients with the opportunity utilize non-pharmacologic remedies, as well. While there are many non-pharmacologic remedies that can be offered, one that has shown some success is biofeedback. According to a study by Rausa et al. (2013), tension in the frontalis muscle was measured to set a baseline and then during the training (p. 3). This study found reduced frequency of headaches, as well as a reduction in the amount of pharmaceuticals needed (p. 6).

In the area where I reside, biofeedback is not an easily accessible option. Patients would have to travel over an hour to receive treatments. However, there are other options that would be more readily available, such as regular massage therapy.

Rene

Rausa, M., Palomba, D., Cevoli, S., Lazzerini, L., Sancisi, E., Cortelli, P., & Pierangeli, G. (2016). Biofeedback in the prophylactic treatment of medication overuse headache: a pilot randomized controlled trial. Journal Of Headache & Pain, 17(1), 1-8. doi:10.1186/s10194-016-0679-9

Week3.Peer.Response.docx

(1 like)

Sherry Boyd

Jul 23, 2017Jul 23 at 7:59pm

Catherine,

Great job on your assessment! I found your post to be very informative. Migraines are something that I do not have any personal experience with. However, I have heard from friends and colleagues how disabling they can be. According to Diener, Charles, Goadsby, and Holle (2015) non-medical approaches to preventing a migraine include exercise, relaxation techniques, counselling, and stress management. These non-medical approaches to preventing migraines are not always effective. Prevention with medication needs to be discussed as necessary. Currently, B-blockers, anti-epileptics, calcium channel blockers, angiotensin II receptor antagonist inhibitors, and antidepressants are used for migraine prevention (Diener, Charles, Goadsby, & Holle, 2015). These medications have been shown to reduce the frequency of migraines by up to 50 % in approximately 45 % of patients (Diener, Charles, Goadsby, & Holle, 2015). The adverse effects of these medications contribute to a reduction in compliance. Research is underway to find a “better” medication to prevent migraines. One type of medication that is showing promising results is an antibody against calcitonin gene-related peptide receptor antagonist (CGRP) (Diener, Charles, Goadsby, & Holle, 2015). For those people who suffer with migraines, hopefully, research continues until there is a proven medication that is beneficial in preventing migraines.

Sherry Boyd

References

Diener, H., Charles, A., Goadsby, P. J., & Holle, D. (2015). New therapeutic approaches for the prevention and treatment of migraine. The Lancet Neurology, 14(10), 1010-1022. doi:http://dx.doi.org.proxy.chamberlain.edu:8080/10.1016/S1474-4422 (15)00198-2

Kara Flatt

Kara Flatt

Jul 23, 2017Jul 23 at 8:11pm

Collapse Subdiscussion Sherry Boyd

Catherine-

Thanks so much for your post! I really enjoyed reading your assessment and summary. My questions revolve around your diagnosis’. If you choose migraine and cervico-discogenic pain as your top 2 priorities, how do you explain the cough? Is is scant and intermitant to where we shouldn’t even worry about it, or is it the dominating factor? As NPs I think it is important for us to see the whole picture. Thanks!

-Kara

Jul 18, 2017Jul 18 at 11:59pm

Collapse Subdiscussion Jessica Allen

Dr. Lunsford and Class-

SOAP Note

T.B., 43 yr. old, Caucasian male, BCBS

CC (chief complaint): Headache, back pain, and cough

HPI:

Onset: Cough began 6 days ago; back pain and headache began 2 days ago

Location: Generalized cough, generalized mid back, generalized frontal headache

Duration: Headache and back pain constant with varying degrees of discomfort, cough consistent

Characteristics: Associated with fatigue

Aggravating Factors: Coughing makes the headache and back pain worse

Relieving Factors: OTC pain medication decreases the back pain and headache

Treatment: Tylenol 650 mg PO every 4 hours for head and back pain; OTC Robitussin 2 teaspoons PO every 4 hours for cough

Current Medications: Simvastatin 20 mg PO at bedtime; Zoloft 100 mg PO daily; Tylenol 650 mg PO every 4 hours as needed for pain; Robitussin cough syrup 2 teaspoons PO every 4 hours as needed for cough Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion.

Allergies: No allergies to food, medication, or environment.

PMHx: Last tetanus vaccine 2012. Last influenza vaccine October 2016. Surgeries include: tonsillectomy 2011 and ORIF right ankle 2016.

Soc Hx: Works as a telecommunication specialist at AT & T. Married with 4 children. Drinks 2 beers approximately 3 times per week. Quit smoking cigarettes 15 years ago, currently uses an ecig. Denies illegal drug use.

Fam Hx:

Maternal grandmother: Parkinson’s; died in her late 80s from complications related to Parkinson’s disease.

Maternal grandfather: Colon Cancer; died in his early 60s from colon cancer.

Paternal grandmother: COPD, obesity; died in her early 70s from COPD.

Paternal grandfather: died in his mid 60s from “blood” cancer

Mother: hypertension, depression

Father: alcoholism, anxiety, depression, hypertension

Son; daughter 1: ADHD, anxiety

Daughter 2; daughter 3: No health issues

ROS:

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

HEENT: Eyes: no difficulty with vision or double vision. No eye pain, discharge, lesions, or inflammation. No corrective lenses. EARS, NOSE, THROAT: No hearing loss, earaches, or drainage. No nasal discharge, congestion. No mouth lesions or pain. No dysphagia.

SKIN: No rash or itching.

CARIOVASCULAR: No chest pain, dyspnea with exertion, orthopnea, palpitations, or cyanosis. No nocturia or edema. (Has hyperlipidemia)

RESPIRATORY: No pain with breathing, wheezing, or shortness of breath. Smoked cigarettes for 11 years x 1 ½ ppd. Pack years: 16.5. Quit smoking cigarettes15 years ago. Currently uses e cig.

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

GENITOURINARY: Denies burning with urination, frequency, or inability to begin urinating.

NEUROLOGICAL: No weakness, dizziness, tremors, memory loss, or paralysis. No numbness or tingling. No change in bowel or bladder control. Has headache.

MUSCULOSKELETAL: No history of arthritis or gout. No joint pain, stiffness, deformity, or limited range of motion. No muscle pain or weakness. (Has joint pain and stiffness bilateral knees and ankles.)

HEMATOLOGIC: No anemia, bleeding, or bruising.

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

PSYCHIATRIC: No history of depression or anxiety (Being treated for depression).

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

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

Physical Exam:

VITAL SIGNS: BP 132/88 R ARM SITTING; 128/86 L ARM SITTING; T: 98.4; HR: 66; RR: 18; HT: 5’11”; WT 250 POUNDS

CONSTITUTIONAL: Well nourished. Articulates clearly, ambulates without difficulty. No apparent distress. Alert and oriented x3.

HEENT:

HEAD: Normocephalic. No lumps, lesions, scaling, or tenderness. Facial features symmetrical.

EYES: No discharge or crusting. Conjunctivae clear. Sclera white; no lesions or redness. Pupils: 3 mm

resting, 2 mm constricted and equal bilaterally. PERRLA.

EARS: Hearing intact. Heard whispered words bilaterally. No mass, lesions, or scaling on outer ear. No

discharge.

NOSE: No deformities or tenderness to palpation. Nares patent bilaterally. No discharge or congestion.

Mucosa pink and intact. No parasinus tenderness upon palpation.

MOUTH/THROAT: Mucosa and gingivae pink and intact. Uvula rises midline. Gag reflex intact.

(Tonsils absent due to tonsillectomy.)

NECK: Supple with full ROM. No masses or lymphadenopathy. Symmetric. Trachea midline. Thyroid

nonpalpable.

CARDIOVASCULAR: Jugular veins flat at 45 degrees. Carotid arteries +2 bilaterally, no bruits. S1-S2

not diminished or accentuated, no S3 or S4. No murmur.

LUNGS/THORAX: Chest expansion symmetric. Tactile fremitus equal bilaterally. No tenderness with

palpation. No lesions or lumps. Hyperresonance over lung fields and equal bilaterally. Respirations not

labored. Vesicular breath sounds clear and equal over lung fields.

ABDOMEN: Symmetric. Abdomen soft, bowel sounds present. No mass, tenderness,

lymphadenopathy.

MUSCLOSKELETAL: Smooth motion of temporomandibular joint. Full range of motion of neck

without pain. No deformity, tenderness of vertebral column. Full extension. Full ROM of arms and legs

bilaterally. Good muscle strength. Muscle flexion maintained against resistance.

NEUROLOGIC: Alert. Oriented to person, place, and time. Speech is clear, easily understood.

CRANIAL NERVES:

1. Visual acuity intact. Peripheral fields intact by confrontation.

III, IV, VI: PERRLA. EOMs intact.

V: Sensation intact bilaterally. Jaw strength strong, equal bilaterally.

VII: Facial muscles intact, symmetric.

VIII: Whispered words heard bilaterally.

IX, X: Swallowing intact, gag reflex present, uvula rises midline. Voice smooth.

XI: Head rotation and shoulder shrug equal and intact bilaterally.

XII: Tongue protrudes midline. Speech clear and distinct.

Each year, people seek medical attention for a cough. Coughing can be caused by many things. It is important for healthcare providers to treat the underlying issue that causes the cough as opposed to treating the cough itself. Based on the chief complaint this week, acute bronchitis is the chosen differential diagnosis. The majority of the time, acute bronchitis is caused by a virus (Kinkade & Long, 2016). Laboratory testing is usually not necessary to diagnose acute bronchitis. The headache and back pain is likely related to extensive coughing. Patients should be encouraged to increase their fluid intake, rest, stop smoking (if applicable), and use a humidifier to add moisture to the air (Hollier, 2016). Cough suppressants can be prescribed to provide night time relief of cough. Antibiotics are not recommended for a viral bronchitis (Hollier, 2016).

References

Hollier, A. (2016). Clinical Guidelines in Primary Care. Scott, LA: Advanced Practice Education

Associates, Inc.

Kinkade, S., & Long, N. A. (2016). Acute Bronchitis. American Family Physician, 94(7), 560-565.

Jessica Allen

Jul 20, 2017Jul 20 at 10:13pm

Sherry, very good work! I chose acute bronchitis as the diagnosis this week as well. When reviewing the chief complaint, it sounded very familiar. I had bronchitis several times a year as a child. I know the coughing and pain all too well. I also read the Kinkade and Long article. I wasn’t aware that cough is the most common illness seen in ambulatory care. Bronchitis can be confused or cover up other illnesses. It is important to review all symptoms and patient history to rule out pneumonia, asthma, or COPD. Acute bronchitis is self-limited and does not require antibiotics. Pneumonia is often treated with antibiotics. Differences in sputum and fever are another good way to differentiate between the two. A chest x-ray will show if the congestion is located in the bronchioles or in the lungs. Treatment should be over the counter medications and not antibiotics. Using antibiotics to treat viral bronchitis is ineffective and leads to antibiotic resistant strains of bronchitis. Over the counter medications used to treat the symptoms are far more helpful than antibiotics (Kinkade & Long, 2016). Neurologic, Musculoskeletal, and Cardiopulmonary Assessment – NR 509 discussion

References

Kinkade, S., & Long, N. A. (2016). Acute Bronchitis. American Family Physician, 94(7), 560-565.

Jessica Allen

Jul 22, 2017Jul 22 at 7:40pm

Hi Jessica,

Great point about the assessment differences with bronchitis and pneumonia. Sometimes we will need to prescribe medications for bronchitis, not just over the counter medications, such as albuterol or prednisone (or other steroids). You are completely correct about not treating the bronchitis with antibiotics. The only exception to this in my current practice is high risk COPD patients.

Dr. L

Sherry Boyd

Jul 23, 2017Jul 23 at 6:42pm

Collapse Subdiscussion Elizabeth Booth

Jessica,

Thank you for the informative response. I did read that bronchitis can be differentiated from other respiratory illnesses by the presence of sputum and fever. It is important to remember that not all illnesses require antibiotic therapy.

Sherry

Elizabeth Booth

Jul 23, 2017Jul 23 at 10:25am

NR509_Week 3_peer response.docx

Sherry,

Like Jessica, I was also surprised to hear that cough is one of the most frequent complaints that patients have when seeking medical care from their primary care provider. I agree with your plan to provide your patient with symptomatic treatment only, rather than pacifying him with a prescription for antibiotics. Patients should be educated on the fact that antibiotics are not recommended based on the presence of purulent sputum or a change in its color. Rather, they are only indicated in cases where pneumonia is suspected, in which patients would display symptoms of tachycardia, tachypnea, fever, and an abnormal chest exam (rales and egophony). Over 23,000 patients die a year from antibiotic resistant infections (Harris, Hicks, & Qaseem, 2016). I would explain to my patient that I do not want him or her to be added to that number. Your plan will ensure that your patient receives proper evidence-based care.

Elizabeth

References

Harris, A., Hicks, L., & Qaseem, A. (2016). Appropriate antibiotic use for acute respiratory tract infection in adults: Advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Annals of Internal Medicine, 164(6), 425-434. doi:10.7326/M15-1840

Sherry Boyd

Jul 23, 2017Jul 23 at 6:45pm

Elizabeth,

Thank you for your response. Antibiotic resistant infections pose a serious risk to many patients. As healthcare providers, we are responsible to limit antibiotic prescriptions to only those illnesses that require antibiotics.

Sherry

Jessica Allen

Jessica Allen

Jul 19, 2017Jul 19 at 12:30am