Question

Musculoskeletal, neurological skills write up from head to toe

Answer 1

#. Musculoskeletal assessment parameters :-

Gait

Stance

Posture

Examination of the joints

Range of motion

1. Gait

The base is as wide as the width of the shoulders. The walk is smooth, even, and well-balanced. Associated movements, such as the arm swing, are present.

2. Stance

Look for :-

symmetry

width

steady

assistive devices

3. Posture

Observe for normal posture

poor posture: kyphosis, lordosis, scoliosis.

4. Examination of the joints

Inspection-size, contour, and appearance: redness, atrophy, deformity, swelling.

Palpation- crepitus ( temporal mandibular joint disorder), bogginess, or tenderness.

5. Range of Motion

Full mobility of each joint.

Deliberate, smooth, accurate, and coordinated.

No involuntary movements.

#. Head to toes neurological assessment :-

- Introduction

• Introduce yourself and tell the patient what you will be doing (head-to-toe assessment) while you wash your hands/hand sanitize.

• Close the curtain or close the door to the room for privacy.

• While you are introducing yourself, assess the patient's mental status and level of consciousness, mood, personal hygiene, skin color, posture/position, mobility, ability to hear and speak.

- Vital Signs

• Assess the patient's vital signs: take their temperature, radial pulse, respirations, and blood pressure.

• While you are taking their blood pressure, pulse, etc., inspect the patient's skin surface characteristics (color, freckles, moles, etc.), temperature, and moisture.

• Inspect patient's hands for symmetry. Inspect nails for shape and contour, cleanliness.

• Test capillary refill and observe for for clubbing of the fingers.

• Also take their height and weight.

- Lower Extremity ROM (Range of Motion) and Romberg Test

Lower Extremities

•After you take their height and weight, tell them to walk toward you on their tip toes.

•Then have them walk the other way on their heels.

•Then tell them to walk heel to toe (in tandem) -- you should be beside them for every exercise/activity you have them do.

•Have them twist side to side at the waist.

•Have them bend to one side and then to the other (like they are touching their hand to the side of their knee).

•Have them bend over and touch their toes while you inspect their spine with forefinger and middle finger spread apart to trace the spine. Make sure you stand at their side when they do this and not behind them.

•Have them stand back up and do the Romberg test (which is part of CN 8 (Vestibulocochlear) with them, standing at their side for support. Have them close their eyes with hands extended out in front of them for 30 seconds.

•Then have them lift one knee, then the other.

•Then extend one leg out, then the other.

•Then extend one leg behind and then back, then the other.

•Then abduct and adduct both legs at the side.

•Have patient rotate their knee toward the outside and then toward the inside. Do with the other leg.

•Then have the patient bring the heel of one foot up toward the shin of the other foot and slide foot down. Do the same with the other side.

•Then have them do foot exercises - stick one foot out, flex, dorsiflex, rotation, then repeat with other foot.

•Then invert and evert your feet.

- Upper Extremity ROM (Range of Motion):

Upper Extremities

•Have them raise both hands above head, then back down.

•Then raise both hands out to the side and back down.

•Extend arms behind and then back, do same with the other arm.

•Have them put arms out in front of them (like they are going to put up their dukes), but then move arm down and then back up again.

•Then have them put hands out. Spread fingers, then together. Make a fist. Hands up toward ceiling, then down towards the ground. Then in a circle/rotate.

•Then inspect neck range of motion. Have them touch their chin to their chest, move head back, touch ear to shoulder and do the same with the other ear, then tell them to rotate head the one way and then the other.

- Then Inspect CN 2 (Optic)

•Now have the patient stand 20 feet away from the Snellen eye chart. Have them cover one eye and read the lowest line that they can.

•Then have them cover the other eye and do the same.

•Then ask them which bar is the longest.

•Then ask them what color is the top bar and what color is the bottom bar (color blind test).

- Review of Systems

•Then go down the list of systems and ask the patient if they are having any of the related symptoms.

- Neurological

•Headaches? Do you wear glasses/contacts? Dentures? Any visual problems? Any dizziness or wooziness?

- Musculoskeletal

•Any muscle or joint pain?

•Back pain?

•Any history of falls or broken bones or fractures?

•Activity level - do you exercise, and if so, how often and what kind of exercise?

•Any mobility aids - walkers or canes, etc?

- Integumentary

•Have you had any rashes or pruritis (itching) lately? Notice any change of color or growth of moles or a mole that is bothersome/itches?

- Respiratory

•Any cough or sputum?

•Any trouble breathing or catching breath?

•Any wheezing?

Cardiovascular

•Chest pain? Leg pain? Shortness of breath with or without activity?

- Gastrointestinal

•Ask about their diet, loss of appetite, increase of appetite, any nausea or vomiting? Diarrhea or constipation? Ask when their last BM was as well as color and if it was loose, formed, hard, etc. Ask what their usual BM schedule is.

- Genitourinary

•Having any troubles with flow? Dysuria (pain while urinating)? Urgency? Hesitancy? Nocturia (urinating during the night)? Hematuria (blood in urine)? What is the usual color? Does it have a pronounced odor? How often would you say you urinate during the day?

- Psychological

•How has your sleep been? How many hours of sleep do you get? Do you have insomnia (trouble falling asleep and staying asleep)? Do you wake up in the middle of the night and have trouble falling back to sleep?

•What are your stressors lately? Family life, job, financial, etc.

•Any change of feelings or depression lately?

•Who are your support systems - family, friends?

- Examine Head and Face

•Tell the patient what you are going to do before you do it. Explain things to them.

•Wash hands and put on gloves.

• Inspect skull for contour and hair for color and distribution as well as texture. Palpate/assess scalp for tenderness, lesions, masses, etc.

• Inspect facial features and symmetry.

•Check TMJ (temperomandibular joint).

- PERRLA, Cardinal Gazes, Look Inside Mouth, Nose, Ears, etc.

Then Inspect CN 3, 4, and 6 (Occulomotor, Trochlear, and Abducens)

Then Inspect CN 9, 10, and 12 (Glossopharyngeal, Vagus, and Hypoglossal)

•Do PERRLA (pupils, equal, round, reactive to light, and accommodation -- look for pupil constriction, etc.)

•Look up their nose (CN 1 - Olfactory) with pen light.

(CN 9, 10, 12)

•Have them open their mouth, look inside with pen light at color, if moist, teeth, etc.)

•Have them stick out their tongue and say ahh.

•Have them stick out their tongue and move it from side to side.

• Inspect the patient's conjunctiva and sclera for color and clarity.

• CN 3, 4, 6 - Check the patient's cardinal gazes. Have them follow your finger with eyes only. Picture to follow.

•Then have them follow your finger as you gradually bring it closer to their nose (testing for convergence) - their eyes should become crosseyed