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Standardized Patient Block 3 Notes Parts of a SOAP note: o Subjective: what the patient tells you OLDCARTS Onset, location, duration, characteristics, aggravating/alleviating, radiating, temporal, severity (at its worst and right now) SMASH-FM (histories) Social, medical, allergies (general and medications (what happens)), surgical (any complications), hospitalizations, family, medications o Social = FEDTACOS Food, exercise, drugs, tobacco, alcohol, caffeine, occupation, sexual Don’t forget to counsel!! Review of Systems (ROS) General: fever, chills, weight loss, nausea/vomiting, SOB, weakness, fatigue Musculoskeletal: unexplained joint/muscle pain, weakness, cramps, stiffness Neurological: double vision, headaches, vertigo (room spinning), numbness, tingling, loss of memory, hallucinations, etc. o Objective (physical exam; what YOU find) Vital signs: Temperature o Normal (oral): 98.6 F o True fever: 100.5 F or higher Blood pressure o Normal: 120/80 or below o HTN: 140/90 or above Respiratory rate o Normal: 12-20 breaths/minute Heart rate (pulse) o Normal: 60-100 beats per minute General statement about patient: Demeanor, appearance, orientation (person, place, time) Physical exam: Cranial nerves (2-12), sensory/motor/reflexes (C5,6,7; L4, S1, etc.) Muscle strength (0-5) Special tests: o Kernig’s, Brudzinski’s, Spurling’s, Lhermittee’s, Romberg, Heelshin, Finger-nose, Dix Hall-Pike o OMM: TART, segmental changes, Chapman’s points o TART = tissue texture changes (acute vs chronic), asymmetry, restricted ROM, tenderness to palpation Assessment: Differential diagnoses: 4 differentials 1 secondary diagnosis o Diabetes, HTN, smoking, alcoholism, obesity, etc. o Plan MOTHRR Medications (name, dosage, schedule, route, duration) OMT (soft tissue, occipital release, muscle energy of C-spine/upper Tspine) Tests o Lab work: CBC, ESR, CRP o Imaging: x-ray, CT, MRI, angiogram Humanistic o Work/school note, support system, does patient understand/accept course of treatment Be sure to document compliance! Referral o Neurologist, ophthalmologist, emergency room Return to visit o Follow up in one week for reassessment o Have patient call if any questions/concerns ahead of time Go to ER if they can’t reach physician or if symptoms worsen Physical Exam o Mental Status AA&O x 4 (Awake, alert and oriented in person, place, time, situation) Mood and affect, thought, perception, memory/cognitive function o Cranial nerve exam (2-12) CN 2 (optic nerve) Test visual acuity via handheld eye chart or snellen chart on the wall Visualize eye via ophthalmoscope Have patient cover one eye at a time, keeping their eye directed forward and wiggle finger from different planes of their peripheral vision and ask when they can see it and/or from what side it is coming from CN 3 (oculomotor nerve) Pupillary light reflex o Shine penlight in patient’s eye Both that eye and the opposite eye should undergo miosis (pupil constriction) Repeat but this time shine light in other eye Accommodation o Have patient focus on your finger/object and bring it close to their face o Pupils should constrict (get smaller) CN 3, 4, 6 (oculomotor, trochlear, abducens) Trochlear nerve: o Innervates superior oblique Down and out motion of eyes Abducens nerve: o Innervates lateral rectus Eye abducts (lateral movement) Oculomotor nerve: o Levator palpebrae superioris Raises upper eyelid o Medial rectus Adducts eye (medial movement) o Superior rectus Eye moves up and in o Inferior rectus Eye moves down o Inferior oblique Eye moves up and out How to test: o Have patient keep head still and have their eyes follow your finger as you move it in all directions (letter H or star movements) o Ask if they experience any double vision o Note any deviation, palsy, nystagmus CN 5 (trigeminal nerve) Sensory: to the face o Test by asking patient if they experience sensation when you stroke the three areas of the trigeminal nerve (V1, V2, V3) V1 = forehead V2 = maxilla (under the eye) V3 = mandible (jaw) Motor: to muscles of mastication o Have patient clench teeth and feel masseter muscles thicken Corneal reflex (V1) o Light stroking of cornea causes BILATERAL blinking CN 7 (facial nerve) Sensory: taste to anterior 2/3 of tongue o Rarely tested (probably don’t have to do) Motor: muscles of facial expression o Test by having patient: Raise eyebrows, squeeze eyelids shut, puff cheeks, smile CN 8 (vestibulocochlear nerve) Cochlear division: hearing o Rinne Test (conductive hearing loss) Hold tuning fork on mastoid process until patient can no longer hear it and then place tuning fork in front of ear Assesses bone vs air conduction of sound o Weber Test (sensorineural and conductive hearing loss) Place tuning fork in middle of head Normal: sound should be heard equally on both sides Sound lateralizes TOWARD side w/CONDUCTIVE hearing loss Sound lateralizes AWAY from side w/SENSORINEURAL hearing loss Vestibular division: balance o Gait examination Have patient walk normally Walk on heels (tests dorsiflexion) Walk on toes (tests plantarflexion) Walk heel to toe (tandem gait) Inability could indicate ethanol intoxication, weakness, vertigo, poor position sense, etc. o Romberg Test: Have patient stand up, feet together, arms at side and close eyes Normal: patient should maintain balance, slight swaying is okay Positive test: patient steps out (can’t maintain balance) o Indicates lesion in proprioceptive pathway CN 8 lesion o o o Patient complains of hearing loss, tinnitus (ringing in ears), vertigo/dizziness, nystagmus CN 9 and 10 (glossopharyngeal and vagus) Sensory: o Taste to posterior 1/3 of tongue Rarely tested (probably don’t have to do) o Sensation to posterior pharynx/tonsils Motor: o Innervates muscles of pharynx/palate o Have patient open wide and say “ahhhh” Look for symmetric elevation of uvula Unilateral loss of function: uvula will not elevate on affected side o Have patient swallow and watch for the larynx to elevate/rise CN 11 (spinal accessory nerve) Innervates trapezius and sternocleidomastoid muscles Have patient shrug shoulders Have patient turn head to one side against resistance (tests the sternocleidomastoid muscle on the side OPPOSITE the direction of head turn) CN 12 (hypoglossal nerve) Motor to the tongue Have patient stick out tongue o Look for fasiculations (twitchings) o If lesion is present, tongue will deviate TOWARD side of lesion Have patient say “lalalalalala” Motor (muscle strength) 0-5 scale 0 = no movement 3 = movement against gravity but not against resistance 5 = normal muscle strength Check muscle tone Have patient relax and move limb o Decreased, normal, increased, rigid, spastic Bulk: look for signs of hypertrophy (enlarged muscle) or atrophy (shrunken muscle) Sensory Light touch: use end of tissue or Q-tip Temperature: use tuning fork Spinothalamic pathway Pain: use pin or sharp edge of broken tongue depressor o o Spinothalamic pathway Vibration: use vibrating tuning fork DCML/PCML pathway Proprioception: have patient close eyes, move distal joint up or down and ask patient to identify what direction you moved the joint DCML/PCML pathway Coordination (cerebellar testing) Assess gait (have patient walk) Finger to nose (have patient alternate touching their index finger to yours and then touching their own nose; repeat) Heel to shin (have patient touch the heel of one foot to the shin of the other) Deep Tendon Reflexes 0-4 scale 0 = no response 1 = slight response 2 = NORMAL 3 = hyperreflexive 4 = clonus (hyperreflexia and shaking) For upper extremity assess: Biceps (C5) o Sensory: area over biceps o Motor: biceps/deltoid actions Patient should be able to flex arm at elbow o Reflex: biceps reflex (tap inferior biceps tendon and elbow should flex) Brachioradialis (C6) o Sensory: radial side of forearm into thumb and index finger o Motor: wrist extensors o Reflex: brachioradialis reflex (tap at tendon between radial side of forearm and wrist, patient should flex wrist up) Triceps (C7) o Sensory: middle finger o Motor: Triceps: patient should extend elbow Wrist flexors Finger extensors o Reflex: triceps reflex (tap at tendon between triceps and elbow, patient should extend elbow) For lower extremity assess: Patellar (L4) o Sensory: medial aspect of foot o Motor: foot inversion o Reflex: knee jerk (patellar reflex) Achilles (S1) o Sensory: lateral aspect of foot o Motor: foot eversion o Reflex: Achilles reflex (tap on Achilles tendon and foot should plantarflex) o Spurling’s Test Passively hyperextend and sidebend patient’s head toward affected side (or maybe in this case to each side) and apply an axial load If patient’s pain is recreated, this is indicative of cervical nerve root disorder o TART changes Acute: Skin is warm, moist, red inflamed Tender, painful Tissue is boggy, edematous (swollen) Chronic: Skin is cool, pale, dry Less tender, more dull/achy Tissue is hard, ropy, thick Possible things we might see our SP present with o Headache Can be acute/episodic (less than 15 a month) or chronic (more than 15 a month) Symptom Location Character Migraine Unilateral Gradual onset Pulsating Worse w/activity Needs quiet and darkness (phonophobia and photophobia) 4-72 hours N/V, may or may not have aura (pre migraine symptoms), neuro deficits Patient appearance Duration Other Symptoms Tesnion Bilateral Pressure/tightening Hat band distribution Comes and goes No specific pattern Cluster Unilateral Quick onset Deep/explosive pain Variable None ½ hr to 3 hrs Ipsilateral runny/red eye, stuffy nose, sweating, etc. Patient can remain active Red Flag Headaches Sudden onset “thunderclap” headache = subarachnoid hemorrhage o Get head CT w/o contrast o Lumbar puncture o o o Headache with stiff neck and signs of infection o Think meningitis, encephalitis Get CBC, ESR, CRP, lumbar puncture Head CT w/o contrast; MRI Treatment: OMT: manipulate at OA joint, cervical spine, T1-T4 Medications: o Acute migraine attacks: Non pharmacologic: ice, rest, sleep in dark/quiet environment Meds: sumatriptan (avoid in those w/cardiovascular disease) NSAIDS: ibuprofen, naproxen o Cluster headaches Acute: inhaled oxygen (100% oxygen via facial mask for 15-20 minutes), sumatriptan Prophylactic therapy: verapamil o Tension-type headache Acute: NSAIDS (ibuprofen, naproxen) Prophylactic therapy: amitriptyline Bacterial Meningitis With meningitis, you don’t delay in treatment Start empiric therapy while labs are being done, then when you get the results back, switch to an antibiotic specific for that organism Most of the organisms that cause bacterial meningitis are affected by 3rd generation cephalosporins: cefotaxime and ceftriaxone o Give IV (admit patient to hospital) Encephalitis Usually viral in origin Treatment is usually supportive Exception: if agent is determined to be HSV, treat w/IV acyclovir Ischemic Stroke Patient can present with: Sudden numbness/weakness of face, arm leg Sudden confusion/aphasia Sudden memory deficit or spatial orientation/perception difficulties Sudden visual deficit or diplopia Sudden dizziness, gait disturbance, ataxia Do blood glucose level (to rule out hypoglycemia), CBC Head CT w/o contrast o o o o o Give tPA if symptoms presented less than 4.5 hrs ago and they’re over 18 yrs old Don’t give if something in their history suggests that they are at increased risk for bleeding If symptoms were more than 4.5 hrs ago, admit them and monitor, possibly give antiplatelet agents (aspirin, clopidogrel) Hemorrhagic stroke Patient can present with: Confusion Agitation/lethargy that progresses to stupor/coma Headache, vomiting, neuro deficits, HTN Do CBC and blood glucose level (to rule out hypoglycemia) Head CT w/o contrast STOP ALL ANTICOAGULANTS AND ANTIPLATELETS (you don’t want them to bleed more!) Get their blood pressure under control Ideal systolic BP of 140 mm Hg Subarachnoid hemorrhage Sudden onset “thunderclap” headache; “worst headache of my life” Patient can also have neck stiffness, N/V, photophobia, seizures, etc. Head CT w/o contrast Lumbar puncture to look for blood or xanthochromia (yellow CSF due to breakdown of old RBCs) Refer to neurosurgery Calcium channel blockers to prevent vasospasm (nimodipine) Transient Ischemic Attack (TIA) Can be thought of as a mini-stroke Transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia, WITHOUT ACUTE INFARCTION 50% of those with a TIA have a full-blown stroke in 48 hrs Admit them for observation!!!! Trigeminal neuralgia Unilateral electric-like pain in one or more divisions of CN 5 Deep, dull ache between attacks Triggers: brushing teeth, chewing, talking, cold wind on face Can get MRI of brain Treat w/anti-convulsant meds (carbamazepine, oxcarbazepine, gabapentin) Facial nerve palsy (CN 7) Unilateral facial weakness, ear pain, hyperacusis (increased hearing on affected side) Most will recover spontaneously o o o Can speed up the process w/prednisone tapered over 3 weeks and/or antivirals (acyclovir for 7-10 days) Glossopharyngeal neuralgia (CN 9) Paroxysmal, unilateral pain in/around throat, jaw, ear, larynx, tongue Deep, aching pain in between Triggers: coughing, swallowing, yawning, cold liquids, etc. Can get MRI Local anesthetic to region of tonsils/pharynx helps with pain Can prescribe same meds as with trigeminal neuralgia Diabetic neuropathy Can be of multiple types (b/c it can affect multiple nerves) Classic presentation: insidious onset of burning pain usually in distal extremities (hands and feet ) Symptoms can precede diagnosis of diabetes (meaning a patient can present w/diabetic neuropathy before they’re diagnosed w/diabetes) Treatment: CONTROL BLOOD SUGAR o Diet, exercise, insulin, metformin, etc. o Treat neuropathic pain (gabapentin)