Linda Hutchison, a 49-year-old Caucasian high school teacher, has…

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Question Answered step-by-step Linda Hutchison, a 49-year-old Caucasian high school teacher, has… Linda Hutchison, a 49-year-old Caucasian high school teacher, has had multiple sclerosis (MS) for over 20 years. She has been very tired lately, has had trouble maintaining urinary continence, is experiencing weakness, and describes a “pins and needles” feeling in her legs. Also, muscle spasms at night are affecting her ability to sleep. She is concerned about an exacerbation of her MS and arrives at her scheduled appointment to discuss ways to prevent this from happening.·       Biographical Data: LH, 49-year-old Caucasian woman. Alert and oriented. Asks and answers questions appropriately. Had been working as an office manager at the local high school, but recently began teaching (her first love) language classes (French and German); she is also responsible for teaching two physical education (PE) classes a week.·       Reason for Seeking Health Care: “I have been so tired and weak lately and have been having trouble with urinary continence and a ‘pins and needles’ feeling in my legs. Leg spasms at night are keeping me awake. I am anxious that I will have an exacerbation of my MS.”·       History of Present Health Concern: The current symptoms began after she recently changed jobs. “I get so tired by the end of the week. If I rest all weekend, I am OK by Monday morning.” Ms. Hutchison has had MS for 20 years but has managed to function at a near-normal level for most of that time. “I had one severe exacerbation during my divorce, but I went into remission after about 6 months.”·       Personal Health History: Ms. Hutchison denies numbness, seizures, or dizziness. She has not noticed a change in sensations of taste or smell, hearing, or vision. Client denies difficulty speaking or swallowing. She denies loss of bowel control. Client denies recent or remote memory loss. Client denies head injury, meningitis, encephalitis, spinal cord injury, or stroke.·       Family History: Ms. Hutchison reports that her mother has hypertension and migraine headaches. Her father and two sisters are in excellent health. Maternal grandmother has hypertension and obesity. Maternal grandfather died because of an automobile accident at age 35. Paternal grandmother has rheumatoid arthritis. Paternal grandfather has coronary artery disease, hypertension, and diabetes type 2. Ms. Hutchinson denies a family history of cerebrovascular disease, epilepsy, brain cancer, or Huntington chorea.·       Lifestyle and Health Practices: Takes oxybutynin (Ditropan) as prescribed for MS. Takes multivitamin daily. Denies use of tobacco or recreational drugs. Reports drinking two to three glasses of wine every 2 to 3 months. Reports wearing a seatbelt always. Denies participation in any activities requiring protective headgear. 24-hour diet recall: Breakfast—cereal with 2% milk and 1 cup of coffee; lunch—plain ham and cheese sandwich, 1 small bag plain potato chips, and an apple, with unsweetened iced tea; dinner—petite filet mignon, loaded baked potato, salad, water.·       Denies exposure to lead, insecticides, pollutants, or other chemicals. Denies frequent heavy lifting or repetitive motions. Reports that she is able to perform ADLs independently. Denies any change in self-esteem or body image.·       Physical Examination Findings: Alert, thin, middle-aged woman with mildly elevated blood pressure and pulse rate (136/92 and 98). According to her chart, Ms. Hutchison’s blood pressure is normally 100/70.·       CN I: Able to correctly identify scents bilaterally.·       CN II: Vision 20/20 right eye, left eye, and both eyes. Visual fields intact. Red reflex present bilaterally. No other internal structures visualized by examiner.·       CN III, IV, VI: Extraocular movements intact. No ptosis noted bilaterally. Slight nystagmus noted when eyes are in extreme lateral positions. Pupils 5 mm, constricting to 3 mm bilaterally. Pupils reactive to light and accommodation.·       CN V: Temporal and masseter muscles contract bilaterally. Able to identify light touch to forehead, cheek, and chin. Corneal light reflex symmetric.·       CN VII: Able to smile, frown, wrinkle forehead, show teeth, puff out cheeks, purse lips, raise eyebrows, and close eyes against resistance.·       CN VIII: Able to hear whispers from 3 ft bilaterally. Weber test with equal lateralization. Rinne test AC > BC.·       CN IX, X: Uvula and soft palate rise symmetrically with phonation. Gag reflex present. Swallows without difficulty.·       CN XI: Equal shoulder shrug with resistance bilaterally. Turns head in both directions with resistance.·       CN XII: Tongue midline without tremor. Strength of tongue intact.·       Motor function: No atrophy of muscles noted. Slight tremors and weakness of leg muscles noted. Full range of motion of all extremities. No fasciculations or tics noted. Unable to walk heel-to-toe without some loss of balance. Romberg sign is negative. Rapid alternating movements and finger-to-nose movements smooth and intact. Heel-to-shin movement smooth and intact.·       Sensory: Identifies light, sharp, and dull sensation to extremities and trunk. Vibratory sensation, stereognosis, graphesthesia, and two-point discrimination are intact.·       Reflexes: 2+ bilateral brachioradialis, bicep, triceps. 4+ patellar. Achilles and plantar reflexes with mild clonus. Abdominal reflex present. Babinski with toe flexion.Step 1 – Describe the patient’s detailed Focused Physical Assessment of the Neurologic system. Step 2 – What worries you? What data is relevant and what is its clinical significance? Step 3 – Are all the facts gathered?  What other information or questions might the nurse need to gather/ consider as you prepare for this client?Step 4 -What is the priority problem/nursing diagnosis? Step 5 – What is the pathophysiology of the problem? Step 6 – Consider developmental, cultural, and nutritional considerations and risk factors when completing health history and physical assessment on the neurologic system  Step 7 -Provide patient teaching as regards to the neurologic system   Health Science Science Nursing HEALTH ASS NR 304 Share QuestionEmailCopy link Comments (0)

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