Health Reflection: Musculoskeletal And Neurological

Health Reflection: Musculoskeletal And Neurological

  • Complete the ShadowHealth© Musculoskeletal and Neurological assignments

Professional Development

  • Write a 500-word APA reflection essay on your experience with the Shadow Health virtual assignment(s). At least two scholarly sources in addition to your textbook should be utilized. Answers to the following questions may be included in your reflective essay:
    • What went well in your assessment?
    • What did not go so well? What will you change for your next assessment?
    • What findings did you uncover?
    • What questions yielded the most information? Why do you think these were effective?
    • What diagnostic tests would you order based on your findings?
    • What differential diagnoses are you currently considering?
    • What patient teaching were you able to complete? What additional patient teaching is needed?
    • Would you prescribe any medications at this point? Why or why not? If so, what?
    • How did your assessment demonstrate sound critical thinking and clinical decision-making? Health Reflection: Musculoskeletal And Neurological

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musculoskeletal Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

Return to Assignment (/assignments/313477/)

Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation

Subjective

This is a 28 yo pleasant African American female. She is the primary source of history and offers information freely. she speaks clearly and coherently and maintains contact throughout the exam. She presents to the clinic with c/o back pain for 3 days. Pain is 5/10, takes advil and pain reduces to 2-3/10. Her pain in her lower back and upper buttocks. Gets worse when she is laying down. Is able to perform her normal activities. Medication: Proventil, albuterol. advil for pain, PRN Med allergy: PCN: hives and rash Medical history: Diabetes no meds Asthma: on Proventil and albuterol. Controlled asthma with meds No surgical history. No hx of trauma No family history of musculskeletal system disease Family history of HTN and Diabetes

HPI: Ms. Jones presents to the clinic complaining of back pain th began 3 days ago after she “tweaked it” while lifting a heavy box while helping a friend move. She states that lifted several boxes before this event without incident and does not know the weight the box that caused her pain. The pain is in her low back and bilateral buttocks is a constant aching with stiffness and does n radiate. The pain is aggravated by sitting (rates a 7/10) and decreased by rest and lying flat on her back (pain of 3-4/10). The pain has not changed over the past three days and she has treated with 2 over-the-counter ibuprofen tablets every 5-6 hours. Her current pain is a 5/10, but she states that the ibuprofen can decrease her pain to 2-3/10. She denies numbness, tingling, mus weakness, bowel or bladder incontinence. She presents today as pain has continued and is interfering with her activities of daily liv Social History:

Ms. Jones’ job is mostly supervisory, although sh does report that she may have to sit or stand for extended period time. She denies lifting at work or school. She states that her pai has limited her activities of daily living. She denies use of tobacc alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats.

• Musculoskeletal: Den muscle weakness, pain, joint instability, or swelling. She does sta that she has difficulties with a range of motion. She does state that pain in her lower back has impacted her comfort while sleeping a sitting in class. She denies numbness, tingling, radiation, or bowel/bladder dysfunction. She denies previous musculoskeletal injuries or fractures. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures.

Your Results Lab Pass (/assignment_attempts/6633867/lab_pass.pd Health Reflection: Musculoskeletal And Neurological

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Document: Provider Notes

Student Documentation Model Documentation

Objective

HENT: WNL No abnormalities found Upper extremities: WNL: no abnormality found: ROM: wnl Spine: reduced ROM for extension and flexion and lateral bending Hips: ROM wnl Lower extremity: Root foot with a scar: healed well. Strength tests all wnl for upper and lower extremities.

General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. maintains eye contact throughout interview and examination. Musculoskeletal: Bilateral upper extremities without muscle atrop or joint deformity. Bilateral upper extremities with full range of mo of shoulder, elbow, and wrist. No evidence of swollen joints or sig of infection. Bilateral lower extremities without muscle atrophy or joint deformity, full range of motion of bilateral hips, knees, and ankles. No evidence of swollen joints or signs of infection. Flexio extension, lateral bending, and rotation of the spine with reduced ROM – pain and difficulty. Bilateral upper extremity strength equa and 5/5 in neck, shoulders, elbows, wrists, hands. Bilateral lowe extremity strength equal and 5/5 in hip flexors, knees, and ankles

Assessment

Lower Back Pain Low back muscle strain related to lifting

Plan

Refer to physical therapy Review body mechanics Advil prn as needed, Discuss exercise and weight bearing exercises Return to clinic if symptoms worsen

Provide Ms. Jones with materials detailing stretching techniques the lower back. • Initiate treatment with ibuprofen 600 mg by mo every six to eight hours with food as needed for pain for the next weeks. She may use acetaminophen 500-1000 mg by mouth eve hours for breakthrough pain. • Ms. Jones can also use adjunct therapy of topical heat or ice per comfort TID-QID.

• Educate on proper body mechanics and lifting techniques. • Educate on the to seek emergent care including loss of bowel or bladder function, acute changes in sensation of lower extremities, or limitations in movement of lower extremities.

• Return to clinic in two weeks for follow-up and evaluation of symptoms. Health Reflection: Musculoskeletal And Neurological

Comments

If your instructor provides individual feedback on this assignment, it will appear here.

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Neurological Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

Return to Assignment (/assignments/313478/)

Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation

Subjective

Ms. Jones is African American pleasant female who presents to the clinic with c/o headache and neck stiffness She was in a slow-moving car accident last week, and her symptoms just started two days ago. She was wearing her seat belt. She has a dull headache at the crown of her head and the back is at the back of her neck. She was no loss of consciousness. She takes tylenol which helps, with the pain 3/10. She feels her neck swollen, but has been resolving recently. Moving her neck hurts. ROS: She denies any fatigue, wt loss, fever or chills. Head: NO trauma, or LOC or dizziness,. Eyes: she wears reading glasses, and gets blurry when she reads to much. Ears:

no hearing loss or ringing of her ears, no vertigo or earache. Denies any neck stiffnes. Musculoskeletal: denies problems with her ROM Denies any neurological disease or problems. No family hx of neurological disease or problems. Medical hx: Diabetes: no meds Asthma: Medications: Albuterol, proventil, tylenol and advil Allergy med: PCN: hives, and rash

HPI: Ms. Jones presents to the clinic complaining of a headache neck stiffness that started 2 days after she was in a minor fender bender. One week ago she states that she was a restrained passenger in an accident in a parking lot and estimates the spee be approximately 5-10 mph. She and the driver did not seek emergent care and felt fine after the accident. Two days later, however, she developed a bilateral temporal dull ache accompanied by a neck ache. She states that she feels as though her neck may be slightly swollen as well. She did not lose consciousness in the accident and denies changes in her level of consciousness since that time. She states that she gets a headache every day that lasts approximately 1-2 hours. She occasionally takes 650 mg of over-counter Tylenol with relieve of the pain. She denies known associated symptoms. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats.

• Head: Denies history trauma before this incident. Denies current headache. • Eyes: Sh does not wear corrective lenses, but notes that her vision has be worsening over the past few years, but no acute changes. She complains of blurry vision after reading for extended periods. De increased tearing or itching. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache.

• Nose/Sinuses: Denies rhinorrhea Denies stuffiness, sneezing, itching, previous allergy, epistaxis, o sinus pressure. • Musculoskeletal: Denies muscle weakness, pai difficulties with range of motion, joint instability, or swelling. • Neurologic: Denies loss of sensation, numbness, tingling, tremor weakness, paralysis, fainting, blackouts, or seizures. Denies bow or bladder dysfunction. Denies changes in concentration, sleep, coordination, appetite.

Your Results Lab Pass (/assignment_attempts/6635634/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Document: Provider Notes

Student Documentation Model Documentation

Objective

Oriented to person, place and time. Judgement and knowledge intact: Memory intact. no slurred speech Head: symmetrical no lesions, no trauma Weber test intact, rinne test intact, facial sensation intact, gag reflex intact Eyes: Blurry vision with prolonged reading: Right eye vision 20/40: retina: with glaucoma cupping. Left eye vision 20/20: retina: sharp edges Pupils: PERRL present Point to point intact for a finger to nose, heel to the shin. Sensation present in extremities except monofilament decreased sensation on foot. Present sensation at heels of both foot. DTR: 2+ for all reflexes Gait: wnl Graphesthesia: able to identify Sterognosis: able to identify

General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress, but appears uncomfortab while sitting in an exam chair. She is alert and oriented. She maintai eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic • Eyes: Bilateral eyes with equal hair distribution.

• Neurologic: Sense of smell intact and symmetric. Left eye visio 20/20. Right eye vision: 20/40. Left fundoscopic exam reveals sh disc margins, no hemorrhages. Right fundoscopic exam reveals retinopathic changes. Pupils equal, round, and reactive to light bilaterally. Extraocular movements intact bilaterally. Normal convergence. Facial sensation intact; facial features and symmet Rinne and Weber tests normal bilaterally. Gag reflex intact. Ability shrug shoulders symmetric; 5 strengths against resistance. Neck full range of motion against resistance; 5 strength against resista Tongue symmetric with no abnormal findings. Bilateral upper and lower extremity DTRs equal and 2+ bilaterally. Point-to-point movements are smooth and accurate for finger-to-nose and heel-to-shin. Rapid alternating movements of the upper extremities intact bilaterally. Gait steady with continuous, symmetric steps. Sensation intact to bilateral upper and lower extremities; a sense of extremity position intact. Stereognosis and graphesthesia are intact bilaterally.

Assessment

Headache and Neck pain due to s/p slow moving MVA Acute post-traumatic headache following low-speed MVA where Jones was a restrained passenger

Plan

Try Motrin 800mg po every 8 hours prn for headache Offer ice or heat to see if it helps with pain Educate on Warning signs: report any increased headache or worsening headaches, LOC, dizziness or vomiting Education on exercises for ROM of neck Report to ER if a headache is severe, LOC, nausea and vomiting, dizziness. Advise having someone with her to watch her for the next 2 days if worsening symptoms. Telephone appt in 2 days to follow up with symptoms. Consider neuro consult if symptoms don’t resolve CAT scan if sx worsens or no improvement

Encourage Ms. Jones to continue to monitor symptoms and repo any increase in frequency or severity of her headaches. • Initiate treatment with ibuprofen 800 mg by mouth every 8 hours as nee with food for the next 5 days. • Ms. Jones can also use adjunct therapy of topical heat or ice per comfort TID-QID. • Educate on stretches for upper back and neck. • Educate on when to seek emergent care including the worst headache of her life, acute changes in vision, hearing, or consciousness, episodes of nause vomiting associated with headache, or numbness, tingling, or paralysis of new onset. • Ask Ms. Jones to call the office in two d to discuss symptoms. If no decrease in symptoms, order a computerized tomography scan or magnetic resonance imaging

Comments

If your instructor provides individual feedback on this assignment, it will appear here.

© Shadow Health 2012 – 2020 (800) 860-3241 | Help Desk (https://support.shadowhealth.com/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents

(https://www.shadowhealth.com/patents) Health Reflection: Musculoskeletal And Neurological