Health assessment

Muscular and Neurologic System

Subjective
1. Chief complaint
a. “My hands and feet have decreased sensation and tingling. My left hand is numb
and I feel like my body has been beaten.”
2. History of present illness
a. Ms. C. is a 28 year old white female who presents to the office with a
complaint of numbness and tingling in both hands and feet which started a
few months ago. She has noticed difficulty performing her job as a secretary
at an accounting firm for the past week because of the symptoms as well as
difficulty focusing at work. She has also been having panic attacks. Thinking it
was just fatigue, she did not seek treatment for some time. Symptoms began
roughly 2 months ago and have progressively worsened to where she now has
some numbness in the left hand and decreased sensation in her right hand,
bilateral feet and intermittent weakness.
3. Past medical history
a. Tonsil and adenoid removal at age 10.
b. Appendectomy at age 14.
c. C-section with second child. 2015
d. Right knee arthroscopy
4. Family history
a. Father diagnosed with cancer 8 years ago. He is alive and well.
b. Mother has no significant health history
c. Husband is a dentist.
d. Has 2 children ages 5 and 2.
5. Social history
a. Works at an accounting firm. Has been there 8 years.
b. Non-smoker.
c. Does not drink alcohol.
6. Review of systems
a. General
i. Young healthy female.
ii. Overall healthy appearance.
b. Skin
i. Afebrile.
ii. Denies bruising or discoloration of skin.
iii. Has decreased sensation on bilateral hands and feet.
c. Eyes:
i. Denies changes in vision.
ii. Wears glasses for reading.
d. Ears
i. Denies changes in hearing.
ii. Denies vertigo or tinnitus.
 e. Nose/mouth/throat
i. Denies nasal congestion and nasal discharge.
ii. Denies difficulty with swallowing.
f. CV
i. Denies chest pain or heart palpitations.
ii. Denies taking medication related to heart or blood pressure.
g. Respiratory
i. Denies shortness of breath or cough.
ii. Has some sleep apnea but does not wear CPAP when sleeping.
h. Genitourinary/Gyn (Defer)
i. Will never assess this area.
i. Musculoskeletal
i. Has no complaints of joint pain.
ii. Has noticed decrease in muscle strength. States that she just feels weak
sometimes.
iii. Right knee will “act up” from time to time from old sports injury. Ice and
rest usually help.
j. Breast (Defer)
i. Will never assess this area.
k. Neurological
i. Confirms some fatigue
ii. Denies syncope or vertigo.
iii. Generalized weakness. Not limited to one or more limbs.
iv. Has some numbness and tingling in both hands and feet occasionally.

Objective
1. Hair
a. No hair loss, loose flakes of skin, or dandruff are seen.
2. Scalp
a. No loose skin or lesions seen, no lumps upon palpation.
3. Skull
a. Normocephalic, no tenderness, depressions, or lumps felt upon palpation.
4. Eyes
a.Denies double vision or blindness.
b.Pupils are equal, round, and reactive to light.
c.Using the opthalmascope and the patient looking straight ahead, no sign of
abnormality while visualizing the optic disk and optic nerve.
d. Cranial nerves 2 and 3 intact as manifested by pupillary reaction to light with
direct and consensual constriction.
e. Cranial nerve 5 intact as manifested by having the patient follow the tip of the
examiners finger with the eyes only without turning the head to assess motor
function of the eyes.
5. Ears
a. Eardrum visualized with otoscope.
 b. Cerumen present, no abnormal discharge noted.
c. Cranial nerve 8 intact as manifested by responding during conversation. Weber
test used to test for more subtle hearing loss by using a tuning fork and placing it
on the forehead of the patient. Patient states it is equal sound in both ears.
6. Nose
a. No discharge or abnormalities seen.
b. No congestion noted.
c. No pain or tenderness upon gentle palpation with the thumbs of the frontal and
maxillary sinuses.
d. Denies changes in ability to smell. Cranial nerve 1 intact.
7. Mouth
a. Mucous membranes moist and pink.
b. Cranial nerve 12 intact as manifested by no deviation with the tongue extended.
c. All teeth intact, no dentures or bridges.
d. Tongue is pink and moist. No evidence of thrush, lesions, or nodules.
e. Class I Mallampati score. Uvula visible, patient able to open mouth without
discomfort.
f. Cranial nerve 5 intact as manifested by manipulation of the jaw such as clenching
teeth. Sensation intact as manifested by using soft and sharp objects and having
the patient identify which is touching her skin.
g. Cranial nerve 7 intact as manifested by equal symmetry of the face when smiling,
frowning, and puffing out the cheeks.
h. Cranial nerves 9 and 10 intact as manifested by movement of hard and soft
palate and no denial of difficulty swallowing.
8. Throat/Neck
a. No pain with flexion or extension and lateral bending.
b. Thyroid gland normal upon palpation and inspection.
c. No wheezing or stridor noted with breathing.
d. Carotid arteries negative for bruit, pulses palpable.
e. No signs of JVD noted.
f. Thyromental distance of 7 cm.
9. Chest/Back/Lungs
a. No signs of anterior or posterior bruising noted.
b. C7 most prominent, use as a landmark to begin palpating the vertebra, no pain
with palpation or stepoff sign (indentation or protrusion of vertebra) noted
c. No evidence of scoliosis with forward flexion or limb length discrepancy when
looking at the hips.
d. Chest expansion equal bilaterally.
e. Lung sounds clear in all fields.
10. Heart
a. Normal S1, S2 heard on auscultation
b. No adventitious heart sounds or murmurs noted when stethoscope placed over
the second intercostal space and just to the right of the sternum over the aortic
 valve, left of the sternum for the pulmonic valve, lower left of the sternum for
the tricuspid valve, and around to the apex of the heart for the mitral valve.
11. Abdomen
a. No signs of bruising
b. Bowel sounds active in all quadrants
c. Absent for bruit
d. No tenderness upon palpation, no evidence of masses or nodules
e. No abnormalities noted upon palpation of liver and spleen
12. Upper Extremities
a. Fingers negative for deformities, redness, and swelling
b. No tenderness with palpation
c. Normal range of motion bilaterally
d. No pain or discomfort with abduction/adduction of the fingers, wrists, elbows
and shoulders
e. Negative for carpel tunnel using the Phalens test (prayer/reverse prayer).
f. Circulation to hands verified using the Allens test. Checking blood flow with
radial and ulnar arteries occluded then releasing one at a time while keeping the
other occluded and visualizing blood return.
g. No tenderness or pain in elbow joints with pronation and supination
h. No pain with Cross arm test (rotator cuff test)
i. Equal strength bilaterally
j. Cranial nerve 11 intact as manifested with shoulder shrug test and turning the
head with resistance against the chin.
k. Warm skin temp, and pulses equal bilaterally
l. No edema noted
m. CRT <3 sec
n. Decreased sensation in left hand noted while using soft and sharp objects and
having the patient identify which side is being used. Patient was unable to tell
which side was being used on the right side and was unable to feel touch on the
left side.
13. Lower extremities
a. Normal range of motion bilaterally
b. No tenderness or pain in joints, no pain with sciatic nerve palpation
c. Equal strength bilaterally as manifested by adduction, abduction, internal, and
external rotation.
d. Denies pain or problems bending with the knees other than what has been there
previously with sports injury as mentioned above.
e. Color, temp, and pulses equal bilaterally
f. CRT > 3 sec
g. Sensation decreased in feet bilaterally noted with inability to recognize soft or
sharp objects touching the skin.
h. Negative for Babinski reflex.
Assessment
1. New diagnosis
a. Progressive onset of numbness and tingling in the hands and feet. Sore muscles
after sleep, inability to focus at work, and panic attacks which are not typical.
2. Further testing
a. Lab work will be done to differentiate between possible Myasthenia Gravis vs.
M.S.
b. CBC, CMP, Anti-MuSK
c. MRI
d. Potential spinal fluid specimen
3. Problem list
a. Numbness and tingling.
i. Bilaterally in hands and feet. Left hand is numb.
ii. Difficulty focusing.
iii. Muscle pain
1. Information to patient
a. I have discussed with the patient about the concern of M.S. vs. Myasthenia
Gravis. It may take time to get a final diagnosis as there is no blood work to
identify M.S. and so tests must be run to rule out one or the other. Given her age
and symptoms, it is most likely M.S. Information has been given to help educate
on both conditions so that she can be aware of any signs or symptoms that may
present themselves.
b. Treatment
i. Corticosteroids for flair ups
ii. Beta interferons (alt/ast lab tests to accompany this)
iii. Potential plasmapheresis
iv. Copaxone if not tolerating interferons
v. Routine check-ups and MRI’s.
2. Patient understanding
a. Patient able to verbalize understanding. Able to explain tests and medications
which will be done for treatment. Understands that she may eventually lose
muscle function if not closely managed.
3. Written/verbal instructions
a. Patient was given teaching packet for smoking cessation and management of
Pulmonary emphysema. Additional information was given to help reinforce
knowledge deficit for signs and symptoms of emphysema and when she should
seek help. Explained to the patient that emphysema is a permanent condition
but can be managed to help her continue managing the farm.
4. Differential diagnosis
a. M.S.
i. The patient presented with progressive numbness and tingling in both
hands and feet. She also was having difficulty focusing at work which
affected job performance. She also stated intermittent muscle weakness
although she presented today without much weakness. Given the patient
 age and presenting symptoms, M.S. is most likely the cause. Lab results
are pending to help assist with final diagnosis.
b. Myasthenia Gravis
i. This diagnosis is less likely due to the lack of evidence during the neuro
muscular exam. Patients with Myasthenia Gravis tend to have limb
weakness, irregular eye movements during the extraocular exam,
abnormal facial expressions with cranial nerve 5 assessment, tremors,
and pins and needles sensation. The one sign that could lead to
Myasthenia Gravis was the muscle pain. This was an indication for further
testing with blood work, MRI, and a possible spinal fluid specimen.
5. Anesthesia specific assessment
a. Respiratory
i. Respiratory muscle weakness and respiratory depression along with
prolonged intubation are key concerns with surgery.
ii. M.S. exacerbation is also a concern during surgical procedures where
anesthesia is involved.
b. Spine
i. With the progressive demyelination of the spinal cord, patients can
become hypersensitive to local and general anesthesia although low
doses are considered safe.
c. Drugs
i. Succinylcholine should be avoided because it can produce hyperkalemia
due to denervation sensitivity by upregulation of acetylcholine receptors.
ii. Patients with M.S. are usually taking steroid supplements and an
intraoperative dose usually given. This will help adrenal suppression.

References

Kulkarni, L. M., Sanikop, C., Shilpa, H., & Vinayan, A. (2011). Anaesthetic management in a
patient with multiple sclerosis. Indian Journal of Anaesthesia, 55(1), 64–67.