SPE #2

Question 1

opening

Answer 1

• Knock on door, wash hands after entering
• Introduce self and job title
• Ask patient for their name, date of birth, and age and check against their name band
• Ask the patient for the day of the week and for their present location (checks awareness)
• Ask the patient whether they have any allergies they are aware of
  o If so, ask what sort of reaction they have
  Open ended question
• What brings you in today?
  Coldspa
• Characteristics
  o Can you explain what you are experiencing?
• Onset
  o When did the symptoms start?
• Location
  o Where is the problem area?
• Duration
  o Is it continuous or intermittent? How long does it last?
• Severity
  o On a scale of 0-10, 0 being no pain/discomfort and 10 being the worst pain you have ever felt, where does it fall?
• Pattern
  o What makes it better? What makes it worse?
• Radiation
  o Does the pain radiate?
  Past medical history
• Have you ever experienced this before? How many times in total? When was the last time? What happened last time? Was it different from what happened this time? Are you taking any medications, prescription or over-the-counter? Any past hospitalizations? Past surgeries?
  (CONTINUE WITH REMAINING QUESTIONS FOR SPECIFIC CONDITIONS)

Question 2

CV assessment

Answer 2

• Have patient lay at 30-45 degrees
  o Visualize the overall skin color. Assess chest wall for lifts, heaves, abnormal pulsations
  o Assess for jugular vein distention
  o Auscultate carotid artery in 3 spots on both sides then palpate in 3 spot on both sides
• Have patient lay in supine position
  o Auscultate at 5 landmarks then in the left lateral position using diaphragm then bell
   Aortic, pulmonic, mitral, tricuspid, Erb’s point
  o While in the lef lateral decubitus position, palpate the apical pulse at the PMI (found in the left 5th intercostal space slightly to the right of the midclavicular line) then have patient return to supine position
  o Arms
   Palpate radial and brachial pulses
   Assess for capillary refill
   Going back up arms, check for warmth and edema
  o Legs
   Palpate popliteal, dorsalis pedis, and posterior tibial pulses
   Assess for capillary refill
   Going back up legs, check for warmth and edema
  o Perform homans sign for thrombophlebitis
   With the patient’s knee slightly bent, sharply dorsiflex the patient’s foot and ask the patient is this maneuver elicits pain in the calf; repeat on other leg

Question 3

neuro assessment

Answer 3

• Observe their motor activity
  o Ask patient if their feeling dizzy
  o Have patient walk normally to the door then tandem walk back to the exam table
  o Perform Romberg test (CN VIII)
• Test the cranial nerves
  o II Test distance vision and near vision; visual fields via confrontation; corneal light reflex (III, IV, VI)
  o III, IV, VI Assess extraocular muscle mobility: cover-uncover test and 6 cardinal fields of gaze
  o VII, XII inspect for facial symmetry while relaxed and while doing expressions; check if tongue midline
  o IX, X Inspect uvula while relaxed and while patient says “ah”; verbalize performing gag reflex
  o V Using a cotton-tipped applicator, test for light touch and pain sensation on the forehead, both cheeks, and jaw; palpate the TMJ as patient bites down repeatedly; have patient keep mouth open against resistance to close it
  o VIII Test gross hearing; whisper test
  o XI Inspect ROM, shoulder shrug, and strength of sternocleidomastoid and trapezius muscle
• Assess ability to perform rapid alternating movements

Question 4

TIA and CVA

Answer 4

Risk factors
- Non-modifiable 
  o Previous TIA
  o Family history 
  o Age 
  o Sex
  o Race 
- Modifiable 
  o Cerebral aneurysm
  o Arteriovenous malformation
  o Diabetes mellitus
  o Obesity
  o Hypertension
  o Atherosclerosis
  o Hyperlipidemia
  o Hypercoagulability
  o Atrial fibrillation
  o Use of oral contraceptives
  o Smoking 
Plus questions
- Are you experiencing palpitations or pounding heart? Diaphoresis? Shortness of breath? Chest pain? Heartburn?  Changes in strength? Changes in sensation? Dizziness? Falls? Any changes in your emotions? Changes in your memory? Have you noticed difficulties with speech? Difficulties with swallowing?
Physical 
- Cardiovascular assessment
- Neurological assessment
Education
- Encourage lifestyle changes, such as smoke and alcohol cessation. Advise patient to adhere to medication regimen; antiplatelet (e.g. aspirin), anticoagulant’s (e.g. Coumadin [long-term use], heparin [short-term use]. Teach range-of-motion exercises to prevent contractures and neuropathies. Teach patient and family the signs and symptoms of a stroke (problems with coordination, paralysis of one side of the body; blurred vision or vision loss; dizziness; difficulty with speech; reduced sensations; mental confusion).

Question 5

angina

Answer 5

Risk factors
- Non-modifiable
  o Gender 
  o Age 
- Modifiable
  o Hypertension
  o Tobacco use
  o Hyperlipidemia
  o Diabetes
  o Stress (occupation, physical exercise, sexual activity)
Plus questions
- Were you exerting the body when the symptoms occurred? Were you under stress when the symptoms occurred? Is the pain predictable? Shortness of breath? Did you feel nausea? Did you have epigastric distress? Diaphoresis? Heartburn? Changes in color of the skin?
Physical
- Cardiovascular assessment
Education
- Inform that angina is a precursor to a more serious condition, a heart attack. Teach the signs and symptoms of a heart attack (extreme chest pain, shortness-of-breath, nausea, vomiting, sweating, anxiety). Inform that angina is usually predictable, if it changes in any way (location, duration) instruct to contact their PCP. Advise to adhere to the medication regimen; nitrates, aspirin, clot-preventing drugs, beta-blockers). Suggest taking frequent rest periods, however, it is important to maintain physical activity to decrease risk of recurrence. Instruct to reduce their salt and fat intake to help prevent hypertension which can worsen anginal pain.

Question 6

MI

Answer 6

Risk factors
- Non-modifiable
  o Gender 
  o Age 
  o Previous MI
- Modifiable
  o Hypertension
  o Tobacco use
  o Hyperlipidemia
  o Diabetes
  o Stress (occupation, physical exercise, sexual activity)
Plus questions
- Were you exerting the body when the symptoms occurred? Were you under stress when the symptoms occurred? Is the pain predictable? Shortness of breath? Have you been experiencing any flu-like symptoms (fever, clammy skin)? Did you feel nausea? Did you have epigastric distress? Diaphoresis? Heartburn? Changes in color of the skin? Activity intolerance?
Physical
- Cardiovascular assessment
Education
- Inform that the most important aspect of management is the medication regimen. Nitroglycerin, a drug that controls and stop chest pain by improving blood going to the heart muscle, should be stored away from light and heat to protect from degradation; aspirin, thrombolytics, antiplatelets, blood thinners, analgesics, beta blockers. Advise to take a nitroglycerin when feeling trademark symptoms of an MI (severe, immobilizing chest pain that may or may not radiate, difficulty breathing, nausea and vomiting, fever)> if symptoms do not completely call 911 before taking another dose of the medication. Educate on lifestyle modifications: a diet low in fats, cholesterol, and salt; long-term rehab includes physical programs.

Question 7

diabetes

Answer 7

Risk factors
- Nonmodifiable
  o Genetic history
  o Ethnicity
  o Women who have delivered infants weighing more than 9 lbs
- Modifiable
  o Obesity
  o Hypertension
  o Inactivity
  o Hyperlipidemia
  o Cigarette use
  o Elevated C-reactive protein
Plus questions
- Have you been experiencing excessive thirst? Hunger? Urination? Unintentional weight gain? Weight loss? Difficulty breathing? Chest pain? Palpitations? Blurred vision? Dizziness? Did you fall as a result of the dizziness? Numbness in your feet? Tingling in your feet? What is your diet normally like? Did you get a pneumococcal vaccine? 
Physical
- Cardiovascular
- Neurological
Education
- Educate on the use of insulin both types of diabetes and oral glycemic medications that help stimulate endogenous insulin production. The DASH diet is recommended to keep blood pressure low; it is low in fat, cholesterol, red meats, sweets and rich in vegetables and fruits and low-fat dairy products. Aerobic exercises on most days of the week is recommended. It is important for you to wear a medical ID bracelet at all times, which will help medical personnel during emergency situations where we would not know who you are and that you have diabetes. Educate the signs and symptoms of both hypoglycemia (dizziness, faintness, headache, nausea, sweating, tingling sensation in legs, confusion) and hyperglycemia (extreme thirst, hunger, and urination, blurry vision, signs of infection). Encourage receiving a pneumococcal vaccine to reduce the risk of infection. Encourage the daily inspection of feet and how to perform proper care due to inc'd risk of foot sores 2o to neuropathies.

Question 8

respiratory assessment

Answer 8

• Anterior
  o Inspect the anterior thorax for shape, symmetry, and integrity of skin
  o Assess respirations for quality and rate, visible signs of respiratory distress (use of accessory muscles, cyanosis, clubbing, labored breathing)
  o Palpate for tactile fremitus
   Using balls of hands, have patient say “99” several times, each time moving hands further down until bases of lungs
  o Auscultate for a full breath (through an open mouth) at each location
• Posterior
  o Inspect the posterior thorax for shape, symmetry, and integrity of skin
  o Palpate for tactile fremitus
   Place hands along patient’s back a “w” with hands further down until bases of lungs
  o Auscultate for a full breath (through an open mouth) at each location

Question 9

COPD

Answer 9

Risk factors
- Nonmodifiable
  o Age
- Modifiable
  o Cigarette smoking
  o Alpha-antitrypsin deficiency
  o Exposure to air pollution 
Plus questions
- Have you been experiencing cough? Is it a productive cough? What does the sputum look like? How much? If you cough, does the sputum clear out of the airway? Shortness of breath? Chest pain? Heartburn? Dizziness? Have you fell as a result to dizziness? Have you received a flu vaccine this flu vaccine? Do you use extra pillows at night to help you breathe better? Do you have an oxygen supply at home? 
Physical
- Respiratory
Education
- Teach patient how to perform deep breathing exercise to manage your shortness of breath and keep the lungs full of air. Suggest that the patient remain in the upright position for most of the time while they are awake as this facilitates breathing. Encourage that patient to increase the amount of fluids, water or other unsweetened beverages, that they take. Collaborate to set up an effective exercise regimen, as extra weight can cause pressure on the lungs which increases difficulties with breathing. On the flip side, it is important to space out activities throughout the day to prevent rapid fatigue. Teach that smoking cigarettes is the number one rik factor, therefore cessation is the single best thing they could do. Encourage getting a flu vaccine each flu season to decrease risk of infection. If patient is using oxygen at home, remind them to always use what is recommended by their PCP to reduce side effects such as atelectasis, oxygen toxicity, or CO2 retention.