Mini Case Study One: Cardiovascular System
Student Number | XXX | Date | |
Clinical Area | Cardiovascular System | ||
Differential Diagnosis | Angina, pericarditis, Aortic stenosis | ||
Summary of Patient History To include PC, HPC, PMH, Drug History, SH/FH System | The 70-year-old make is suffering from chest pain in the last month. Besides, the pain increases with physical activity, which is accompanied by fatigue and shortness of breath, making it hard to carry on daily activities. The patient is under blood pressure medication and has a past history of rheumatic fever. He smokes, drinks, and lives with his wife and son. | ||
System Examination (as per insert key text used ) | Physical examination revealed a harsh systolic murmur. It is very loud and is heard over the second right sternal broader and radiates to the apex. | ||
Critical Analysis 500 words +/- 10% | |||
In an examination of a cardiac, observation is keen for the Corrigan’s sign. This is forceful and bounding carotid pulse, which increases in size and collapses subsequently (Czarny, M. and Resar, J. 2014, 17). This is because of an increase in the volume of stroke of the left ventricle and diminished peripheral resistance. The Corrigan’s sign is an indication of chronic, severe aortic regurgitation (AR) (O’Brien, E., 1980, 36) Sir Dominic Corrigan was an Irish physician who, at thirty years of age, described the collapse of the carotid arteries and visible distention among those with the deficiency of the aorta. In 1832, he published his work on the aortic valve deficiency. He later became the president of the Royal College of Physicians in 1859. However, Corrigan’s work was met with a lot of criticism from other scholars who believed they were the first to discover the relevance of aortic insufficiency and pulsation (Roberts, W. and Dodderer, J. 2017, 436.). James Hope claimed to have discovered the disease seven years before Corrigan did. However, O’Brien (1980) notes that the specific patient that Hope talked about as the basis of his work refers to the mitral valve and thus not applicable in work done by Corrigan (37). The disease received this named after a suggestion from a French physician, Armand Trousseau, describing a sign indicating aortic valve disease (Zacek, 2018). Aortic valve disease is a term that involves the prevalence of aortic stenosis. However, according to Michelena, H., and Enriquez-Sarano, M. (2018), Corrigan’s sign has been correlated to AR. There is a distinct difference as to whether Corrigan’s sign is a term referring particularly to AR prevalence or a just a term more broadly used. This might be misleading to several practitioners and led to misdiagnosis. As much as there may be conflict on the literature surrounding Corrigan’s sign, most correlate the findings to aortic valve deficiency, thus leading the practitioner to obtain input from a cardiology specialist. The inaccuracy as a result of cardiac examination may occur if practitioners emphasize the study of single signs rather than many symptoms (Hanna, I. and Silverman, M. 2002, 263). Other signs could be an indication of AR presence such as heart sounds and collapsing pulse, although research has connected the presence of Corrigan’s sign to aortic valve abnormality by a practitioner performing a comprehensive examination (Ruthven, A. 2016, 2). A study of the effectiveness of AR in clinical practice discovered that over ninety percent of literature available at the time affirmed the clinical importance of the Corrigan’s sign in analyzing AR (Mallinson, T. 2017, 14). It is therefore straightforward to practitioners to conduct a non-invasive clinical practice. In conclusion, Corrigan’s sign is still in extensive clinical practice today; the terms related to the insufficiency of the aortic valve, which calls for specialist input by the practitioner. This concept of cardiac examination is not difficult to assess because the findings have years of research to show its importance. They can guide the practitioner in identifying the right specialty for patients.
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References
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing. Menlo Park, CA: Addison-Wesley.
Czarny, M. J., and Resar, J. R. (2014). Diagnosis and management of valvular aortic stenosis. Clinical Medicine Insights. Cardiology, 8(1), 15–24.
Grimard, B., Safford, R., and Burns, E. (2016). Aortic Stenosis: Diagnosis and Treatment, Am Fam Physician, 93(5), 371-378.
Mallinson, T (2017). A survey into paramedic accuracy in identifying the correct anatomic locations for cardiac auscultation. British Paramedic Journal. 2 (2): 13–17.
McLoughlin, M., and McLoughlin, S. (2012). Cardiac auscultation: Preliminary findings of a pilot study using continuous Wave Doppler and comparison with classic auscultation. Int J Cardiol. 167, 590–59.
Ohm, F., Vogel, D., Sehner, S., Wijnen-Meijer, M., and Harendza, S. (2013). Details acquired from medical history and patients’ experience of empathy–two sides of the same coin. BMC medical education, 13, 67.
Ruthven, A. (2016). Essential Examination. Scion Publishing Ltd.
Shellenberger, P., Balakrishnan, B., Avula, S., Ebel, A., and Shaik, S. (2017). Diagnostic value of the physical examination in patients with dyspnea. Cleve Clin J Med. 84(12):943-950.
O’Brien, E., 1980. Corrigan’s disease. J Ir Coll Physicians Surg, 10, pp.32-7.
Hanna, I.R., and Silverman, M.E., 2002. A history of cardiac auscultation and some of its contributors. The American journal of cardiology, 90(3), pp.259-267.
Mini Case Study Two: Respiratory
Student Number | XXX | Date | 17/6/2019 |
Clinical Area | Respiratory System | ||
Differential Diagnosis | Chronic obstructive pulmonary disease (COPD), pneumonia, and asthma. | ||
Summary of Patient History To include PC, HPC, PMH, Drug History, SH/FH System | The patient was a 68-year-old male who presented with productive and harsh cough experienced over the last seven days before seeing the practitioner with the sputum thick and yellow at times having blood. The patient further indicated that he was suffering from a fever over the week. Past medical history suggests that he has experienced a choric smoker’s cough over the last 20 years, stating that the cough was non-productive and frequently happened in the morning. He revealed that he has been smoking two packets of cigarettes daily over the last 30 years. In the past, he has been treated with mild hypertension and bronchitis. He lives with his wife and spends his days looking after his grandchildren, who live with him. | ||
System Examination (as per insert key text used ) | Physical examination using palpation was undertaken with thumbs placed on the patient’s ribs and surrounding surface areas. The palpation revealed systematic chest movement and increased fremitus as the patient talked. | ||
Critical Analysis 500 words +/- 10% | |||
Pleural Effusion (PE) refers to an imbalance of the formation of fluid and absorption within the pleural space (Hooper, C. et al., 2010, 8). It can be due to malignancy with where the most prominent symptom is dyspnoea which corresponds with presentations from the patients (Baid, H. 2006, 711) Percussion involves chest tapping the patient to ascertain the tissue conditions and the underlying organs (Smith and Rushton, 2014, 35). According to Bickley, L. (2012). Effective percussion involves practitioner placement of their middle finger of the non-dominant hand across the chest and using the fingertips of the dominant hand to tap over the distal interphalangeal joint. There should be an analysis of the chest from the apex to the base of each lung (Sarker, M. et al., 2015, 161). Thus the practitioner will be able to make comparisons of vibrations and sounds which are felt upon percussions aiding in abnormalities detection. The above mentioned diagnostic method is credited to a Viennese physician Joseph Leopold Auenbrugger for its discovery in 1761. According to Harris, A. (2006), Auenbrugger drew his inspiration from witnessing his father tap wine barrels and identifying the difference in sound when the fluid was present (35). He analyzed this method by injecting liquids into deceased people and identifying the difference in sounds (Volmar, A. 2013). The percussion was an invaluable tool for physicians because this discovery took place before the invention of auditory auscultation with a stethoscope in 1816 (Roguin, A. 2006, 1787). However, Volmar, A. (2013) disagrees with this and argues that for half a century, percussion was ignored after its discovery by Auenbrugger. It was also victim to criticism because his teacher was at the time performing abdomen percussions at the time. As much as the literature can present differing arguments on percussions, its relevance in today’s medical practice cannot be disregarded. Clinicians need to conduct percussion in case of a chest examination due to its responsiveness in the diagnosis of effusion (Reyes, F. and Le, 2019). According to Baid, H. (2006), percussion is essential in the diagnosis of a PE as the clinician will discover dullness over the area filled by fluid (713). This is further strengthened by a study by Sharp, C. and Rozanski, E. (2013), where they discovered percussion dullness was the most useful in the diagnosis of PE. This is different from the standard resonant note in chest percussion, which is naturally hollow and heard when abnormalities are absent. The limitation of this method of diagnosis is that it is heavily dependent on judgment, and sound interpretation can be different among physicians (Delmas, P. and Tambini, M. 2014, 32). This idea is valid because the sound heard from a hollow or air-filled space is not the same as sound heard from an area with is filled by fluid. Thus, in case of practitioners lack confidence in their interpretations because of the different sounds, this would call for more investigations. In conclusion, percussion is a reliable crucial tool in the examination of respiratory. Dullness presence will indicate the probability of PE diagnosis according to literature. It requires no equipment and fairly easy to perform as from the clinician perspective allowing percussion to be a respiratory examination tool providing a wide variety of evidence supporting differential diagnosis of a PE until the confirmation of radiology. | |||
Word Count: 550 |
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References
Baid, H. (2006). The process of conducting a physical assessment: a nursing perspective. British Journal of Nursing, 15(13), 710-4.
Bickley, L. (2012). Bates’ Guide to Physical Examination and History-Taking. Lippincott Williams & Wilkins.
Delmas, P., and Tambini, M. (2014). Clinical examination of respiratory function, Rev Infirm. 20 (1), 31-3.
Modi, P., and Tolat S. (2019). Vocal Fremitus. Treasure Island (FL): StatPearls Publishing.
Murray, J. (2010). Murray and Nadel’s textbook of respiratory medicine (5th ed.). Philadelphia, PA: Saunders/Elsevier.
Nair, G., and Niederman, M. (2011). Community-acquired pneumonia: an unfinished battle. The Medical Clinics of North America. 95 (6), 1143–61.
Reyes, F., and Le, J. (2019). Lung Exam. StatPearls Publishing.
Ruthven, A. (2016). Essential Examination. Scion Publishing Ltd.
Sharp, C., and Rozanski, E. (2013). Physical examination of the respiratory system. Top Companion Anim Med., 28(3), 79-85.
Smith, J., and Rushton, M. (2014). How to perform a respiratory assessment, Nursing Standard. 30 (7), 34-36
Mini Case Study Three: Musculoskeletal System
Student Number | XXX | Date | 12/6 |
Clinical Area | Musculoskeletal System | ||
Differential Diagnosis | Osteoarthritis, Baker’s Cyst, crystal-induced inflammatory arthropathy | ||
Summary of Patient History To include PC, HPC, PMH, Drug History, SH/FH System | The patient is a 67-year-old female who presents with knee pain, which increases when she is going up the stairs, taking walks, or acquiring a load. The pain is relieved when she is rested and wakes with morning stiffness, which reduces when she becomes active. She states that she has been experiencing pain in the last years with the pain worsening in the previous month and has started to limit her ability to play tennis and takes walks. She has diabetes and under the medication, and she is overweight. She has been living in an elderly care center in the last three years. | ||
System Examination (as per insert key text used ) | Observation of the knee revealed redness, which indicates a pathology. Further, palpation illustrates the decreased range in motion of the knee, joint effusion, crepitus, and osteophytic changes in the knee joint. | ||
Critical Analysis 500 words +/- 10% | |||
The rotator cuffs involve the culmination of tendons and muscles surrounding the shoulder joint. According to Beran, M. (2013), rotator cuff shoulder injuries are common injuries of MSK, which may require surgical repair. Due to the indefinite history of the patient, a thorough MSK operation was performed. It is important to take a history and conduct necessary examinations to identify the right diagnosis for the treatment of rotator cuff injuries (Browne, L. and Merrill, E. 2015, 932). According to Iversen, M. et al. (2016) they report that there is no sufficient isolated test that can diagnose rotator cuff damage. Thus, emphasize the significance of a thorough MSK assessment in collaboration with diagnostic tests such as the X-ray. Observations of the injuries brought concerns of RCT. According to Ilori, T. et al. (2017), RCT is the inflammatory and degenerative injury on the shoulder. It is usually brought about by trauma or advances from the rotator cuff disease. In the case of surgical repair, RCT has unsuccessful surgical repair operations on the elderly and in large tears (Maricar, N. 2016, 559). There may be some assurance, considering the patient is only nineteen years old. Nonetheless, it would be necessary to involve orthopedic to examine the tear size and offer advice on the management plan, which is influenced by the patient’s pain and the assessment of MSK. Conservative management can be employed in RCT in consideration to particular patients such as highly active patients, and tear progression and the patient’s recovery time. According to a study by Stansfield, R. (2016), smoking and tear sizes contributed to the risk factors tear progression in non-surgical repairs. Peitzman, S. and Cuddy, M. (2015) solidify the above findings when it comes to RCT risk factors as they examined patients with non-traumatic, unilateral shoulder injuries and discovered a strong association with smoking and RCT development (208-211). There has been a direct relationship between the effects of smoking on healing from RCT, where Cheema, A. et al. (2019) asses both smokers and non-smokers after surgical repair and RCT conservative management. They discovered that patient smokers had unlikely favorable outcomes with ongoing pain. Social smokers had a difficult time with their recovery. According to Cheema, A. et al. (2019), study rats with a significant amount of nicotine experienced a delay in tendon to bone healing. Nicotine is considered a vast-contrictor; thus oxygen supply will depreciate leading to delayed healing (Stansfield, R. 2016) In conclusion, there is a distinct connection between delayed healing from-RCT and smoking. More research should be conducted concerning infrequent smokers and the effect of RCT because there is still a lack of awareness on the level of harm people expose themselves to. The patient in the case study came to the health care facility presenting with left knee pain, which increases when weight is put on it Word count:470 |
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References
Beran, M., Awan, H., Samora, J., Rowley, D., Griesser, M., and Bishop, J. (2013). Assessment of musculoskeletal physical examination skills and attitudes of orthopedic residents. The Journal of Bone and Joint Surgery, 94(6), e36.
Browne, L., and Merrill, E. (2015). Musculoskeletal Management Matters: Principles of Assessment and Triage for the Nurse Practitioner. The Journal for Nurse Practitioners, 11(10), 929 – 939.
Ilori, T., Ladipo, M., Ogunbode, A., and Obimakinde, M. (2016). Knee osteoarthritis and perceived social support amongst patients in a family medicine clinic, South African Family Practice, 58(6), 202-206.
Iversen, M. D., Price, L. L., von Heideken, J., Harvey, W. F., and Wang, C. (2016). Physical examination findings and their relationship with performance-based function in adults with knee osteoarthritis. BMC musculoskeletal disorders, 17, 273.
Iwamoto, J., Sato, Y., Takeda, T., and Matsumoto, H. (2011). Effectiveness of exercise for osteoarthritis of the knee: A review of the literature. World J Orthop, 2(5), 37-4
Lespasio, M. J., Piuzzi, N. S., Husni, M. E., Muschler, G. F., Guarino, A., and Mont, M. A. (2012). Knee Osteoarthritis: A Primer. The Permanente Journal, 21, 16–183.
Maricar, N., Callaghan, M. J., Parkes, M. J., Felson, D. T., and O’Neill, T. W. (2016). Clinical assessment of effusion in knee osteoarthritis-A systematic review. Seminars in Arthritis and Rheumatism, 45(5), 556–563.
Peitzman, S., and Cuddy, M. (2015). Performance in a physical examination on the USMLE Step 2 Clinical Skills examination. Acad Med. 90(2), 209–13.
Phillips, D., Zuckerman, J., Strauss, E., and Egol, K. (2013). Objective Structured Clinical Examinations: a guide to development and implementation in orthopedic residency. J Am Acad Orthop Surg. 21(10), 592-600.
Ruthven, A. (2016). Essential Examination. Scion Publishing Ltd.
Stansfield, R. B., Diponio, L., Craig, C., Zeller, J., Chadd, E., Miller, J., and Monrad, S. (2016). Assessing musculoskeletal examination skills and diagnostic reasoning of 4th-year medical students using a novel objective structured clinical exam. BMC Medical Education, 16(1), 268.
Cheema, A.N., Newton, J.B., Boorman‐Padgett, J.F., Weiss, S.N., Nuss, C.A., Gittings, D.J., Farber, D.C. and Soslowsky, L.J., 2019. Nicotine impairs intra‐substance tendon healing after full-thickness injury in a rat model — Journal of Orthopaedic Research®, 37(1), pp.94-103.
Mini Case Study Four
Student Number | XXX | Date | 17/6/2019 |
Clinical Area | Abdominal System | ||
Differential Diagnosis | Ruptured abdominal aortic aneurysms, peritonitis, acute appendicitis, ureterolithiasis, and acute cholecystitis | ||
Summary of Patient History To include PC, HPC, PMH, Drug History, SH/FH System | The patient is a 35 year old female presenting with abdominal tenderness as well as pain. Also, she states that she is experiencing nausea and vomiting, as well as diarrhea and loss of appetite. The patient communicates she had pancreatitis and peritonitis in the past. She says that in the last two days, she has been unable to still whereby no position is comfortable for her. | ||
System Examination (as per insert key text used ) | Abdominal | ||
Critical Analysis 500 words +/- 10% | |||
Cholangitis refers to the combination of obstruction of the biliary tree and infection, which can be fatal. Thus, a comprehensive abdominal examination is necessary (Lederle, F. and Simel, D. (2009). Observation of spider naevi signs is necessary within this examination for a practitioner. Spider naevi are vascular lesions, usually five to ten millimeters in size (Johnson, A. et al., 2018). The spider association emanates from their centriole arteriole with thin legs emitting from the body. Definite liver disease is indicated by the presence of more than five spider naevi (Reuben, A. 2016, 145). This particular patient had eight spider naevi to his chest Nonetheless, it has been noted that spider naevi presence also occurs in the oral use of contraceptives and pregnancy due to increased estrogen which causes dilation and increased vessel permeability (Lopez, N. et al. 2011). This is critical in clinical practice when examining other patients, where the practitioner knows that the presence of spider naevi does not only conclude to liver disease. However, due to the patient’s gender and a history of liver cirrhosis, no other plausible explanation was left. The above mention characteristics were first described by an English medic Erasmas Wilson in 1869, where hepatologist William Bean researched it for years, and he linked the scattering to areas that were drained in the superior vena cava. This included the upper torso, neck, arms, and the face (Reuben, A. 2016, 147). According to McGee, S. (2012), she states that the reasons this area is affected are yet unknown. Because there was no presence of spider naevi elsewhere in the body of the patient except his chest, thus directly relates to the examination. Spider naevi have been known to arise from liver diseases, thus enabling a lot of research in alcohol-dependent patients. The spider naevi are highly prevalent in patients who exhibit liver cirrhosis compared to patients with alcoholic hepatitis and cirrhosis (McGee, S. 2012). Thus, the findings suggest that the presence of spider naevi indicates severe liver disease. Another study by Qi, X. and Han, G. (2014), solidifies the above-mentioned study where they discovered that spider naevi presence, including other tests such as platelets count and ascites presence, are the most reliable test that can indicate if a patient with a history of liver disease has cirrhosis. This applies in this examination as the patient under investigation had a history of liver disease, and also from the literature, it indicates that the patient has ascites. It is more challenging to identify the presence of spider naevi in patients with darker skin complexion (Mendiratta, V. and Gretchen, M. 2017). Thus it is essential to form practitioners to be aware of the different ethnic groups. In this case, the patient resides in coastal areas and may, therefore, have sunburned skin familiar to people living along the coast. This might present a challenge when examining the patient. In conclusion, it is relatively easy to look out for spider naevi, and most literature has associated it with cirrhosis. However, this is not an indication of a diagnosis but an abnormality. Thus, an examination should include a comprehensive historical examination of the patient’s records and detailed examination. Word count:536 |
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References
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing. Menlo Park, CA: Addison-Wesley.
Lederle, F., and Simel, D. (2009). Does this patient have an abdominal aortic aneurysm? In: DL Simel, D Rennie, eds. The Rational Clinical Examination. New York, NY: McGraw‐Hill Medical.
Lopez, N., Kobayashi, L., and Coimbra, R. (2011). A Comprehensive review of abdominal infections. World journal of emergency surgery, 6 (7)
Lynn, B. (2012). Bates’ Guide to Physical Examination and History-Taking, 11th Edition. Lippincott Williams & Wilkins.
McGee, S. (2012). Evidence-Based Physical Diagnosis, 3rd Edition. Philadelphia, PA: Elsevier-Saunders.
Mendiratta, V., and Gretchen, M. (2017). History, Physical Examination, and Preventative Health Care – Abdominal Exam. Comprehensive Gynecology. Clinical Key: Elsevier, Inc.
Mishra, S. P., Tiwary, S. K., Mishra, M., and Gupta, S. K. (2014). An introduction of Tertiary Peritonitis. Journal of emergencies, trauma, and shock, 7(2), 121–123.
Qi, X., and Han, G. (2014). Abdominal‐wall varices in the Budd‐Chiari syndrome. N Engl J Med., 370, 1829.
Reuben, A. (2016). Examination of the abdomen. Clinical Liver Disease, 7(6), 143–150.
Ruthven, A. (2016). Essential Examination. Scion Publishing Ltd.
Samuel, J. C., Ludzu, E. K., Cairns, B. A., Varela, C., and Charles, A. G. (2013). A patient with severe peritonitis. Malawi medical journal: the journal of Medical Association of Malawi, 25(3), 86–87.
Johnson, A., Mitchell, D., Batchelor, S., Kaura, S., and Islam, M., 2018. An Unusual Case of Dyspnoea in a Patient with Chronic Liver Disease. Res Rep Gastroenterol 2, 1, p.2.
Mini Case Study Five
Student Number | XXX | Date | 17/6/2019 |
Clinical Area | Neurological Motor and Sensory | ||
Differential Diagnosis | Stroke, hydrocephalus, Parkinson’s disease | ||
Summary of Patient History To include PC, HPC, PMH, Drug History, SH/FH System | A patient is a 65-year-old man who presented with symptoms of tremor, temporary movement inability, and the inability for posture balance. The patient’s wife reports that he has been experiencing decreased interests in the day to day activities as well as difficulties in falling asleep. Besides, the patient is suffering from blood pressure and is medicated. | ||
System Examination (as per insert key text used ) | The practitioners utilize inspection to note reduced expressions on the face, speaking in a soft voice and reduced, sweet voice, and reduced spontaneous movements. Further, at rest, an asymmetrical tremor was observed and involved in his thumb and forefinger, particularly apparent when the patient was not paying attention. When asked to extend his arms, there was a re-emergent tremor recorded in his left hand. The practitioners observed a flexed left arm and neck, reduced arm movement, short stride lengths, and illustrated hesitance when asked to turn. The inspection suggests that the patient has Parkinson’s disease. | ||
Critical Analysis 500 words +/- 10% | |||
The practitioner is presented with tremor, temporary movement inability as well as inability to have posture balance. The practitioner chooses to utilize inspection based on the presenting symptoms of the patient as he felt that he would gather more information through the method as there were various physical cues and non-verbal communication from the patient (Rigg and Anderson, 2010; O’Brien, 2014). Inspection is one of the methods of conducting a physical exam in a patient and can be utilized in carrying out a neurological exam (Massano and Bhatia, 2012). Inspection can be used and result in spot diagnosis whereby information is gathered from watching the patient. Fisher (2012) that spot diagnosis can be acquired as a lot of data can be revealed by observing the patient. The consultant directed and advised the practitioner to ensure that they commence the inspection from when the patient opens the doors to the examination room and throughout the examination. Ruthven (2016) indicate that general inspection allows for the practitioner to gather non-verbal cues from the patient. Following these recommendations, the practitioner watched the patient as he walked into the room and observed that the patient was using a walking aid, which suggests impairments of posture and instability. Chou et al. (2010) indicate that difficulties in waking indicate a significant gait problem. DeMaagd and Philip (2015) also recommend close monitoring of the tone and speech ability of the patient. The practitioner noted that the patent was not able to provide a clear history with his wife, who had accompanied him to the examination doing most of the talking. Inspection, as stated by Nicholl and Appleton (2014), enabled the practitioner to make a critical assessment whereby he noted reduced facial expressions and reduced spontaneous movements. Asymmetrical tremors, as well as soft voice, were also pointed out with the patient hesitate to turn when asked to do so. One flaw in the assessment was that the practitioner tended to talk and communicate with the wife as he had trouble hearing the patient. This resulted in the patient’s frustrations, which he described to the wife. According to Soundy et al. (2014), when assessing patients, including those who have trouble expressing themselves, it is essential to ensure that respect is provided at all times, and efforts are made to involve the patient in the assessment process. The consultant involved the patient in the conversation to ensure he was comfortable and did not feel left out. The practitioners faced challenges in conducting the neurological examination due to the patient’s status, and distractions are the patient moved around the room. According to Ruthven (2016), reduced method application will result in false results or failure in identifying signs of particular conditions. The practitioner does not have prior experience in undertaking a neurological examination and, as per Benner’s (1984) framework, can be categorized as a novice. However, as recommended by Ruthven (2016), the practitioner intends to develop his skills in neurological history and physical examination and become an expert who can appropriately screen and investigate patients. Based on the inspection and symptoms portrayed, the practitioner concluded that the patient had Parkinson’s disease. Word count: 517 |
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References
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing. Menlo Park, CA: Addison-Wesley.
Chou, K., Amick, M., Brandt, J., et al. (2010). A recommended scale for cognitive screening in clinical trials of Parkinson’s disease. Mov Disord, 25, 2501–7
DeMaagd, G., and Philip, A. (2015). Parkinson’s disease and Its Management: Part 1: Disease Entity, Risk Factors, Pathophysiology, Clinical Presentation, and Diagnosis. P & T: a peer-reviewed journal for formulary management, 40(8), 504–532.
Fisher, L. (2012). Assessment of patients presenting with headache. InnovAiT, 5(11), 645–652
Massano, J., and Bhatia, K. P. (2012). Clinical approach to Parkinson’s disease: features, diagnosis, and principles of management. Cold Spring Harbor perspectives in medicine, 2(6), a008870. doi:10.1101/cshperspect.a008870
Nicholl, D., and Appleton, J. (2014). Clinical neurology: why this still matters in the 21st century. J Neurol Neurosurg Psychiatry. 86, 229–33.
O’Brien M. D. (2014). Use and abuse of physical signs in neurology. Journal of the Royal Society of Medicine, 107(10), 416–421.
Rigg, C., and Anderson, R. (2010). Vertigo. InnovAiT. 3, 638–645.
Ruthven, A. (2016). Essential Examination. Scion Publishing Ltd.
Soundy, A., Stubbs, B., and Roskell, C. (2014). The experience of Parkinson’s disease: a systematic review and meta-ethnography. The Scientific World Journal, 613592. doi:10.1155/2014/613592
Mini Case Study Six
Student Number | XXX | Date | 17/6/2019 |
Clinical Area | Cranial Nerves | ||
Differential Diagnosis | Chronic paroxysmal hemicrania, migraine, SUNCT syndrome, cluster headache, and Trigeminal neuralgia | ||
Summary of Patient History To include PC, HPC, PMH, Drug History, SH/FH System | The patient was a 54-year-old female who presented with a headache on one side of the head and temple. The patient complained of shock-like pain on one side of her face. The patient lives on her own but lives near her eldest sister, who reports that she was depressed and expressed thoughts of suicide since experiencing the headache. The headache has been occurring over the past week and has further experienced restlessness. She works as a secretary at a company and is engaged to be married within the year. The patient has a history of tobacco smoke and alcoholism. The patient says that she is always in fear of when the next pain will attack and how severe the pain will be and, as such, is continuously anxious. She states that it has interfered with activities of daily living. | ||
System Examination (as per insert key text used ) | Cranial Nerves | ||
Critical Analysis 500 words +/- 10% | |||
The vestibulocochlear nerve is analyzed through an instrument referred to as the tuning fork (TF). It conducts two specific tests, which are the Rhine test and the Weber test. Through these tests, the examiner will be able to examine the loss of hearing and, if present identifies whether it is sensorineural or conductive (Hegarty, A. and Zakrzewska, J. (2011). Through Weber’s test, a struck TF is positioned in the middle of the forehead (Hsu, A. et al. 2019). Sounds are better heard on the normal ear in the case of sensorineural deafness while the sound is heard in the abnormal ear if there is a presence of conduction deafness. On the other hand, during Rhine’s test, a struck TF is positioned on the mastoid bone, and the patient responds when sound is absent. Afterward, the fork is placed on the external ear. They are present in patients with normal hearing air conditioning is higher than bone conditioning. Patients should be able to hear the TF to the outer ear after it stops on the mastoid. In regards to conduction deafness, when the TF is placed on the external ear, patients would not be able to hear the sound while in sensorineural deafness sound to both the outer ear and mastoid would be reduced significantly. Ernst Weber is credited for discovering Weber’s test of 1825 by McGurgan, I. and Nicholl, D. (2017). In 1955, just thirty years later, Rinne, Heinrich, found the Rinne test, both employing TF. In urgent settings of care, the TF is highly efficient as they are readily available and aid with the first diagnostics in hearing impairments (Dutta, R. and Crawley, J. 2019); this related to the authors as the assessment was conducted in an urgent care area. Nonetheless, it did not match up to their practice as it was time consuming and challenging to obtain TF. McGurgan, I. and Nicoll, D. (2017) support the view that TFs are impractical in clinical practice (323). Their results are misleading and depend on the experience of the clinician and consistently provide abnormal results. To detect a deficit, audiometry is the most reliable way. Rinne and Webber’s results varied greatly in their study compared to audiometry (Kelly, E. et al., 2018, 223). Research has recommended the use of various sizes when conducting these tests, which may confuse clinicians. However, no literature has been found in regard to Weber’s test size. In conclusion, TF use is challenging due to its availability, and it is preferable to use its vestibulocochlear nerve by listening to the patient if they are to report a deficit in hearing. However, it lacks sufficient to experience, leading to a lack of confidence; it is best to go for further clinical practice. More research should be conducted in urgent care areas because the literature discovered only focuses on audiology where more sensitive tests can be done, this is not possible in a critical care setting. Word count:485 |
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References
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