Get Answer: Write History Physical Question Guide
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Original Question
write up a history and physical assessment and patient-centered care plan for the neurological and musculoskeletal systems. Use the assessment templates below to guide your work. The video is just a demonstration of physical assessment skills. The written template is where you describe your findings. Do not write in complete sentences, but document like writing a nurse’s note: for example: DTR’s 2+ bilat, ROM intact chief complaint must be in the system you are working on. Neurological/Musculoskeletal Systems Past Medical History Assess for: Musculoskeletal System: muscle pain, weakness, joint swelling, joint pain, stiffness, limitations in range of motion, limitations in mobility, back pain. Nervous System: pain, seizures, fainting, changes in cognition, changes in memory, problems in coordination, tremor, spasms, changes in sensation. Pertinent Family History Lifestyle, Personal, Social, Environmental Social Determinants of Health Medications SUBJECTIVE: CHIEF COMPLAINT (In the patient’s own words) Review of Systems ALLERGIES: HISTORY OF PRESENT ILLNESS Complete, clear, and chronologic account of the problems prompting the patient to seek care related to this body system. SYMPTOM ANALYSIS ITEM QUESTIONS TO ANSWER PATIENT RESPONSE Onset When did (does it start)? Setting in which it occurs including environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed. Location Where is it? Does it radiate? Duration How long does it last? Characteristics What is it like? How severe is it? Associated Manifestations Have you noticed anything else that accompanies it? Relieving/Exacerbating Factors What makes it better? What makes it worse? Treatment What have you done to treat this? Was it effective? OBJECTIVE: VITAL SIGNS TEMPERATURE PULSE RESPIRATIONS BLOOD PRESSURE SP02 PAIN (Numeric Scale of 0-10 with 10 being the worst) DIAGNOSTICS (Labs) NURSE PHYSICAL FINDINGS FROM EXAM NEUROLOGICAL MUSCULOSKELETAL ASSESSMENTS NEUROLOGICAL MENTAL STATUS CRANIAL NERVES SENSORY SYSTEM Pain Temperature Light Touch Vibration Proprioception (Joint Position Sense) Discriminative Sensations Number Identification (Graphesthesia) Two-Point Discrimination Point Localization Test extremities for superficial tactile sensation Superficial pain sensation Vibratory sense (use tuning fork) Position sense Object recognition (Stereognosis) DEEP TENDON REFLEXES Note symmetry; Grade intensity of each use. (Scale in text) Triceps (tests C6, C7) Biceps (tests C5, C6) Brachioradialis (tests C5, C6) Patellar (tests L2, L3, L4) Achilles Tendon (tests S1) Plantar and Babinski Clonus MUSCULOSKELETAL INSPECT: UPPER EXTREMETIES Inspect shoulders and shoulder girdle for equality of height Inspect wrists and hands for position, contour and number of digits Size/Symmetry Color Texture Hair (distribution) Nail Beds Edema PALPATE Palpate the shoulders, elbows, wrists and hands for firmness, edema, tenderness and masses Observe range of motion of shoulders, elbows and wrists. Test the muscle strength of the shoulders, elbow and wrists and digits Test Phalen and Tinel’s sign Shoulders Elbows Wrists Metatarsophalangeal joints Capillary Refill ROM and MUSCLE STRENGTH Shoulders (Flex, Exten, Abduc, Adduc, Int. Rot, Ext. Rot) Elbows (Flex, Exten, Supination, Pronation) Wrists (Flex, Exten, Radial Dev, Ulnar Dev) Fingers (Flex, Exten, Abduc, Adduc, Int. Rot, Ext. Rot) SPECIAL TECHNIQUES Sensation: Arms Vibration: Fingers INSPECT: LOWER EXTREMETIES Inspect the hips, knees and feet for symmetry and alignment and the number of toes Size/Symmetry Color Texture Hair (distribution) Nail Beds Edema PALPATE Spine Palpate the spinal processes and paravertebral muscles for alignment and tenderness Lower extremities Palpate the hips, knees, ankles and feet for stability, tenderness and edema Hips Knees Metatarsophalangeal Joints Spine ROM and MUSCLE STRENGTH Observe the range of motion of hips, knees, ankles, toes Test the muscle strength of lower extremities Hips (Flex, Exten, Abduc, Adduc, Int. Rot, Ext. Rot) Knees (Flex, Exten, Internal rotation, external rotation) Ankles (plantar flexion, dorsiflexion, inversion, eversion) Spine (Flex, Exten, Rotation, Lateral flexion) SPECIAL TECHNIQUES Sensation: Legs Vibration: Toes ASSESSMENT: SUMMARY OF MAJOR PROBLEMS (Provider narrative of relevant information gathered from analysis of the Subjective and Objective sections above. Must include all aspects of system assessment provided) PLAN: PLAN FOR THE PATIENT BASED ON THE PROBLEMS IDENTIFIED IN “ASSESSMENT” (Provide the priority nursing interventions that would be performed for this patient next. Rationale for each nursing intervention needs to explain why this is the best intervention for this patient scenario, and must be evidence based.) 1. Rationale: 2. Rationale: work citation of the rationales.
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