temperature is warm and no pretibial edema is noted. His toes feel cool and appear normal. ROM and Muscle Strength PW has normal ROM and muscle strength in his ankles and feet. His neurologic function is intact, knowing the following: Name - Paul Williams, Date of Birth - 01/20/1979, Year - 2014, President - Obama, State - Oregon, Where are we now - Mount Hood Medical Center, Who I Am - Sabrina. He answered all question correctly, indicating that he is alert and oriented. PW has a normal sensation response to pain and cold to his face, arms, hands, legs, and feet. His position sense and cerebellar function (finger to nose and heel to shin) are intact and normal. PW’s stereognosis is normal; he was able to identify all objects. He has a positive response to his deep tendon reflexes; biceps, triceps, branchioradialis, patellar, and Achilles. He also has a positive Babinski reflex bilaterally. Musculoskeletal PW is able to walk across the room heel to toe, walk on tiptoes, then on heels, and perform shallow knee bends. He also has a normal Romberg sign. ROM of the spine is normal for him. He has a slight decrease of ROM in his spine related to his history of Kyphosis and Kyphoplasty. PW is a very healthy individual who currently has a few minor medical issues, acid reflux, seasonal allergies, and back discomfort. He currently treats these issues with over-the- counter medications. He mentioned several physical conditions that may need future follow up
ADVANCED NURSING PRACTICE FIELD EXPERIENCE-TASK 2 8 if they become more problematic; light headedness, heart palpitations, “small bladder” with hesitancy and dribbling, and periodic arm numbness. Also, he should be mindful of his family history of hypertension and depression. D1. Identify labs or tests that should have been ordered based on your assessment findings. As a practitioner I would recommend that this patient, PW, should follow up with his primary care physician to obtain a baseline set of lab work. This is based upon the current findings on his comprehensive health assessment of light headedness, heart palpitations, “small bladder” with hesitancy and dribbling, arm numbness, seasonal allergies and acid reflux. Also, with his family history of hypertension, depression, and lupus, it would be relevant to gather a baseline of the following labs for future reference: fasting lipid panel, complete blood count, comprehensive panel, hemoglobin A1c, thyroid stimulation hormone, prostate-specific antigen, erythrocyte sedimentation rate, antinuclear antibody, urinalysis and 25-hydroxy vitamin D. If PW’s acid reflux becomes more problematic to the point where the oral medication he is currently taking is no longer working, further diagnostic testing may be indicated; such as barium swallow or endoscopy. Providing that his seasonal allergies can no longer be controlled with oral medications, additional investigation with either allergy skin testing or serum-specific IgE antibody testing may indicate better treatment options. If PW’s periodic hypoglycemia
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- Winter '16