Pulses: Popliteal posterior tibial dorsalis pedis Bilateral popliteal, posterior tibial, and dorsalis pedis pulses present, 2+ regular Temperature and pretibial edema Skin temperature warm, dry, smooth. No pretibial edema present. Toes No skin breakdown, full range of motion, no discoloration or dryness. No open sores, no joint redness, no edema, no deformities in toes or nails ROM and Muscle Strength Ankles and feet Full range of motion in ankles and toes, no joint swelling noted, no tenderness, even hair 9
distribution, no dryness, no swelling, no skin breakdown Neurologic Alert and oriented x4, calm, cooperative, and appropriate Sensation: face arms hands legs feet Equal and bilateral sensations to face, arms, hands, legs, and feet. No numbness, no tingling, no decreased sensations Position sense Position sense normal to both upper and lower extremities bilaterally Stereognosis Able to identify three objects (pen, paperclip, clothespin) appropriately Cerebellar function (finger to nose) Cerebellar function intact (finger to nose), no Cerebellar function (heel to shin) Deep tendon reflexes: biceps triceps brachioradialis patellar achilles Babinski reflex Musculoskeletal Walk across room heel to toe No scissoring, swinging, shuffling, or waddling noted, pt balanced appropriately Walk on tiptoes, then walk on heels Pt able to do so appropriately, no swaying, waddling, scissoring, or shuffling noted. Pt able to balance appropriately Romberg sign Romberg test negative, no swaying or loss of balance. No cerebellar or sensory ataxia noted. Shallow knee bend Able to complete shallow knee bed appropriately, no pain or difficulty reported. ROM of spine Full range of motion in spine. Pt able to bend forwards and back, laterally, and rotates appropriately. No scoliosis or kyphosis noted, no tenderness to palpation. Social Determinants: 10
1. Can you tell me about your job? 2. How far do you have to travel for your job? 3. Can you describe your housing situation? Do you have adequate housing? Do you own your house? Do you have a mortgage? Do you have house insurance? Are you able to make those payments appropriately and on time? 4. What is your highest level of education? What is your degree in? Do you use your degree for your job? 5. Tell me about your support system. Who are they? Do they live close? 6. Do you live in a rural or urban community? Do you have access to community resources? 7. Describe your access to healthcare and pharmacists. Do you have access to primary care? Urgent care? Emergency care? Pharmacies? Dental? Eye care? How far do you have to travel for these? 8. Do you have health insurance? Are you able to afford it? 9. Describe the options in your community for health and nutritious foods. Are they close by? Are they affordable? How far away are they? Do you cook? 10. Describe any environmental concerns you have in your community, such as water supply, toxins, etc. Do you feel safe in your community? High crime rates? Do you feel safe at home? 11
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- Spring '16
- Shelley Ashby