Neurologic, Musculoskeletal, and Cardiopulmonary Assessment Essay
Subjective:
The patient, a 40-year-old female, presents with the chief complaint of headache, back pain, and cough. She reports that her headache is a dull ache in the frontal area and has been persistent for the past three days. The back pain is localized to her lower back and is aggravated by movement, especially when bending or lifting objects. She mentions having a non-productive cough that started about a week ago and is accompanied by occasional shortness of breath. She denies any history of trauma, recent illnesses, fever, chills, or chest pain.
Objective:
Neurovascular Exam:
– Cranial Nerves: All cranial nerves (I-XII) appear intact and function within normal limits.
– Pupils: Equal, round, reactive to light and accommodation (PERRLA).
– Muscle Strength: Strength is 5/5 bilaterally in all major muscle groups.
– Sensation: Patient reports normal sensation to light touch and pinprick in all extremities.
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Musculoskeletal Exam:
– Inspection: No visible deformities or abnormalities noted in the spine or extremities.
– Palpation: Tenderness and tightness observed in the lower lumbar region.
– Range of Motion: Limited range of motion in the lumbar spine due to pain.
– Muscle Strength: Muscle strength 5/5 in upper and lower extremities bilaterally.
Cardiopulmonary Exam:
– Heart: Regular rate and rhythm, no murmurs or extra heart sounds heard.
– Lungs: Bilateral lung expansion and clear breath sounds heard on auscultation.
– Peripheral Vasculature: Radial and pedal pulses palpable and equal bilaterally.
Assessment:
Based on the neurovascular, musculoskeletal, and cardiopulmonary assessments, the patient presents with tension-type headache, acute lower back pain likely due to musculoskeletal strain, and an upper respiratory tract infection with associated cough.
NURS6051 Health Information Patient Handout Assignment
Plan:
Recommend over-the-counter pain relief for headache, along with relaxation techniques. Advise the patient to rest and apply ice to the lower back for pain relief. Encourage maintaining good hydration and using cough drops to alleviate cough symptoms. Suggest monitoring for any worsening of symptoms and seeking medical attention if the cough persists or worsens.
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