Linda Hutchison, a 49-year-old Caucasian high school teacher,has had multiple sclerosis (MS) for over 20 years. She has beenvery 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 herability to sleep. She is concerned about an exacerbation of her MSand arrives at her scheduled appointment to discuss ways to preventthis from happening.
- Biographical Data: LH, 49-year-oldCaucasian woman. Alert and oriented. Asks and answers questionsappropriately. Had been working as an office manager at the localhigh school, but recently began teaching (her first love) languageclasses (French and German); she is also responsible for teachingtwo physical education (PE) classes a week.
- Reason for Seeking Health Care: “Ihave been so tired and weak lately, and have been having troublewith urinary continence and a ‘pins and needles’ feeling in mylegs. Leg spasms at night are keeping me awake. I am anxious that Iwill have an exacerbation of my MS.”
- History of Present Health Concern:The current symptoms began after she recently changed jobs. “I getso tired by the end of the week. If I rest all weekend, I am OK byMonday morning.” Ms. Hutchison has had MS for 20 years, but hasmanaged to function at a near-normal level for most of that time.“I had one severe exacerbation during my divorce, but I went intoremission after about 6 months.”
- Personal Health History: Ms.Hutchison denies numbness, seizures, or dizziness. She has notnoticed a change in sensations of taste or smell, hearing, orvision. Client denies difficulty speaking or swallowing. She deniesloss of bowel control. Client denies recent or remote memory loss.Client denies head injury, meningitis, encephalitis, spinal cordinjury, or stroke.
- Family History: Ms. Hutchison reportsthat her mother has hypertension and migraine headaches. Her fatherand two sisters are in excellent health. Maternal grandmother hashypertension and obesity. Maternal grandfather died as a result ofan automobile accident at age 35. Paternal grandmother hasrheumatoid arthritis. Paternal grandfather has coronary arterydisease, hypertension, and diabetes type 2. Ms. Hutchinson denies afamily history of cerebrovascular disease, epilepsy, brain cancer,or Huntington chorea.
- Lifestyle and Health Practices: Takesoxybutynin (Ditropan) as prescribed for MS. Takes multivitamindaily. Denies use of tobacco or recreational drugs. Reportsdrinking two to three glasses of wine every 2 to 3 months. Reportswearing a seatbelt at all times. Denies participation in anyactivities requiring protective headgear. 24-hour diet recall:Breakfast—cereal with 2% milk and 1 cup of coffee; lunch—plain hamand cheese sandwich, 1 small bag plain potato chips, and an apple,with unsweetened iced tea; dinner—petite filet mignon, loaded bakedpotato, salad, water.
- Denies exposure to lead, insecticides, pollutants, or otherchemicals. Denies frequent heavy lifting or repetitive motions.Reports that she is able to perform ADLs independently. Denies anychange in self-esteem or body image.
- Physical Examination Findings: Alert,thin, middle-aged woman with mildly elevated blood pressure andpulse rate (136/92 and 98). According to her chart, Ms. Hutchison’sblood pressure is normally 100/70.
- CN I: Able to correctly identifyscents bilaterally.
- CN II: Vision 20/20 right eye, lefteye, and both eyes. Visual fields intact. Red reflex presentbilaterally. No other internal structures visualized byexaminer.
- CN III, IV, VI: Extraocular movementsintact. No ptosis noted bilaterally. Slight nystagmus noted wheneyes are in extreme lateral positions. Pupils 5 mm, constricting to3 mm bilaterally. Pupils reactive to light and accommodation.
- CN V: Temporal and masseter musclescontract bilaterally. Able to identify light touch to forehead,cheek, and chin. Corneal light reflex symmetric.
- CN VII: Able to smile, frown, wrinkleforehead, show teeth, puff out cheeks, purse lips, raise eyebrows,and close eyes against resistance.
- CN VIII: Able to hear whispers from 3ft bilaterally. Weber test with equal lateralization. Rinne test AC> BC.
- CN IX, X: Uvula and soft palate risesymmetrically with phonation. Gag reflex present. Swallows withoutdifficulty.
- CN XI: Equal shoulder shrug withresistance bilaterally. Turns head in both directions withresistance.
- CN XII: Tongue midline withouttremor. Strength of tongue intact.
- Motor function: No atrophy of musclesnoted. Slight tremors and weakness of leg muscles noted. Full rangeof motion of all extremities. No fasciculations or tics noted.Unable to walk heel-to-toe without some loss of balance. Rombergsign is negative. Rapid alternating movements and finger-to-nosemovements smooth and intact. Heel-to-shin movement smooth andintact.
- Sensory: Identifies light, sharp, anddull sensation to extremities and trunk. Vibratory sensation,stereognosis, graphesthesia, and two-point discrimination areintact.
- Reflexes: 2+ bilateralbrachioradialis, bicep, triceps. 4+ patellar. Achilles and plantarreflexes with mild clonus. Abdominal reflex present. Babinski withtoe flexion.
Step 1 – Describe the detailed Focused Physical Assessment ofthe Neurologic system.
- Discuss the Cranial Nerve Assessment
Step 2 – What worries you? What data is relevant, what is theclinical significance of each data and identify the relevance ofthe data to the situation?
Step 3 –What is the priority problem/nursing diagnosis. What arethe signs and symptoms /client behaviors commonly seen with thisproblem?
Step 4 –. Are all the facts gathered? What other information orquestions might the nurse need to gather/ consider as I prepare forthis client
Step 5 Describe any biased thought or personal beliefs thatmight prevent you from objectively looking at this situation.
Step 6 – Consider developmental, cultural, and nutritionalconsiderations and risk factors when completing health history andphysical assessment on the neurologic system
Step 7 -Provide patient teaching as regards to the neurologicsystem
