The musculoskeletal exam I conducted on Ms. Jones went on well because she was able to answer all questions appropriately thus easing my data collection process (Bickley, 2013). Her complaint was that the pain she experienced was from lifting a box, which had started three days before she had visited the clinic (Alexander, Aslam, & Marino, 2017) . I was impressed with the way the patient responded to my questions and she raised my morale and confidence of working with Shadow Health. Te musculoskeletal exam is important to provide an assessment of how the structures will assist in recognizing the joints alignments and appearance. With that, it assists in recognizing the basic abnormalities (Bickley, 2013). On the other hand, the neurological exam seeks to evaluate a person’s nervous system.
Considerably, the musculoskeletal exam went on well but there was a problem of missing questions as well as others that Ms. Jones was not in a position to answer was a major challenge. In my next assessment, I hope to improve on the questions I ask to my patient as well as try in coming up with appropriate questions (Alexander et al., 2017). About the neurological results, the recordings did not match with the questions I presented to Ms. Jones. In the next assessment, I hope to also sharpen my skills since I have become more enlightened. Some of the findings were that she had type 2 diabetes with a blood pressure of 141/80 (Gross, Fetto, & Rosen, 2015) . She is also obese and she was a patient that was undergoing treatment for abdominal pain. However, her major complaint was that she was having a back pain three days before she had visited the clinic. Her pain hurts when she sits but relieves when she is lying down (Gross et al., 2015).
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The question of what was her main complaint and why she had decided to visit the clinic was what yielded much information. About the neurologic aspect, when I narrowed down to asking the reason of her visiting the facility as well as the chief complaints she had raised prompted to other questions (Alexander et al., 2017). Ideally, all of the information that she presented allowed me to engage in a series of thoughts that with time helped me in coming up with a plan. X-ray or MRI is important in the musculoskeletal diagnosis however, I would start by educating her about these tests (Bickley, 2013). For the neurological test, I would recommend monofilaments, or x-ray. Some differential diagnoses include the inflammation and muscle strain for the musculoskeletal and the neck soreness and post traumatic headache for the neurological diagnoses.
After conducting a proper assessment on Ms. Jones, the musculoskeletal findings were such that while Ms. Jones was lifting the box, her backbone might have been injured thus, I would recommend applying cold packs to relieve pain and heat packs to reduce inflammation (Gross et al., 2015). I would also suggest that she continues taking over the counter anti-inflammatory medications. I would also encourage her to exercise lightly when her symptoms subside (Gross et al., 2015). When she goes to bed, her head should be in a raised position for system reduction and safety. However, if her symptoms would persist, I would recommend that she seeks a medical attention. About neurologic findings, Ms. Jones was diagnosed with severe cases of headaches (Bickley, 2013). With that, she was prescribed to take ibuprofen when taking food. She was also told to apply ice at least thrice a day. Other findings included changes in hearing or consciousness, vision, tingling or numbness (Alexander et al., 2017).
As for the musculoskeletal, I would not recommend a medication because the anti-inflammatory medications among other over the counter drugs are working (Gross et al., 2015). As for neurological, I would prescribe her to take ibuprofen to assist in killing pain or the inflammation. While conducting the musculoskeletal exam, I felt confident during the entire interviewing process and I was able to sharpen my thinking skills from the different choices I had made (Bickley, 2013). I was also able to gain evidence-based practice in caring for the patients.
References
Alexander, M., Aslam, H., & Marino, R. J. (2017). Pulse article: How do you do the international standards for neurological classification of SCI anorectal exam?. Spinal cord series and cases , 3 (1), 17078.
Bickley, L. S. (2013). Bates’ Guide to Physical Examination and History Taking Elevent Edition.
Gross, J. M., Fetto, J., & Rosen, E. (2015). Musculoskeletal examination . John Wiley & Sons.
Matuszak, J. M., McVige, J., McPherson, J., Willer, B., & Leddy, J. (2016). A practical concussion physical examination toolbox: evidence-based physical examination for concussion. Sports health , 8 (3), 260-269.
