Nursing 523 Midterm Discussion
Nursing 523 Midterm Discussion
History of present condition: George is a 50 yo business executive who presents with complaints of weakness in his feet and ankles, and inability to walk. His toes and feet are numb and tingly. He feels like his is unable to walk secondary to weakness in his legs. His low back is painful, and he had an episode of urinary incontinence this morning. His fingertips are also tingly. He’s brought by his wife, and with his 2 nephew’s to help him walk. He feels like he is getting much worse. Past medical and surgical history
� Intermittent back pain. He states he has a long standing problem with his back with occasional exacerbations after a weekend of working in the yard. Sometimes he will engage in physical activity, like playing softball or basketball on the weekends, which will cause him to have problems for several days. 5 days ago, he was cutting and stacking firewood, but didn’t finish because he didn’t feel very well. Doesn’t remember hurting back but was doing some twisting and lifting, which has caused him back pain before.
� No surgeries Allergies
� Medicinal allergies: Denies � Environmental allergens: Denies � Food allergens: NKDA
2
Medications: Ibuprofen prn. Lifestyle General: Works for a telecommunications industry as an executive. Some travel, most recently 2 months ago to Chicago. Married, no kids. Physical activity: Fairly sedentary. Limited exercise except on weekends. Sleep: Has not been sleeping well in last week secondary to GI distress (resolving) and back pain. High risk behaviors: ETOH moderately on weekends, none in last week secondary to vomiting and diarrhea episode. Smokes 1ppd x 20 years. No recreational drugs. Diet Usually normal diet, somewhat high in fat and calories. Trying to “do better” with chicken and fish instead of red meat, but had recent vomiting and diarrhea after eating chicken, and hasn’t been interested in chicken since. Relevant review of systems
ROS: General malaise, some wt loss over last week. Cardiovascular: Denies chest pain Respiratory: Denies cough, shortness of breath. Gastrointestinal: Denies present nausea, vomiting or diarrhea. Had 3-4 day course of v/d (nonbloody) last week after eating chicken. Resolved. Drinking fluids. Not much appetite. Genitourinary: No dysuria. Incontinence of urine this am. Musculoskeletal: Feels weak, mostly in legs. Throbbing, achy low back pain, buttock and legs. Integumentary: Denies rashes or bruising. Neurological: Denies headache, neck pain. Numbness, tingling and burning sensation in feet, toes and fingertips.
Physical exam BP: 105/66 RR:16 temp:100.8 pulse:62 ht:70 in wt:220 lbs RA Sat 97%
� General: awake and alert, oriented x 4. Appears tired, but nervous, sitting in wheelchair.
� HEENT: normocephalic, atraumatic. Pupils =, reactive to light and accommodation. Ears clear, oropharynx without signs of redness, lesions. Airway patent. Speech clear. Neck supple. Full range of motion.
3
� Lungs: clear to auscultation bilaterally. Easy unlabored on room air. � CV: S1S2, no rubs, no murmurs. � Abdomen: mild abdominal obesity, otherwise normal. Soft, nontender. � Extremities: warm, well perfused. No edema. � Back: No midline pain to thoracic or lumbar spinous processes. Atraumatic.
Tender to palpation to bilat lower lumbar paraspinal region. � Skin: no rashes or lesions � Neuro: Cranial nerves II-XII grossly intact. Motor: 2+/5 bilat toe flexion and
extension, ankle flexion and extension symmetrically. Quads 3+/5 bilat and symmetric. All other muscle testing 5/5. Reflexes: Unable to obtain bilat ankles, 1+ bilat knees, biceps, brachioradialis 2+ triceps. Sensory: Dysesthesias in bilat legs below knees, sacral area and all fingers on exam to light touch. Unable to stand for exam secondary to weakness.