Download Standardized Patient Block 3 Notes

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
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o
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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
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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
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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
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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
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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
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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)