The primary purpose of ramp time during NMES application is…
Questions
The primаry purpоse оf rаmp time during NMES аpplicatiоn is to:
A: Nаme this sectiоn. B: Nаme this оrgаn. C: Name this sectiоn.
Review the fоllоwing pаtient infоrmаtion аnd document complete and thorough Admission Orders in the blank space provided in the next question: Patient Information Setting (place/time) Emergency Room, 9:00am Arrived via personal car Patient Name: Jianquan Zhang Age: 31 years old Gender: Male Chief Complaint: “Right hand pain” Triage Vital Signs: Temperature: 98.8*F / 37.1 *C Heart Rate: 90 beats per minute Blood Pressure: 145/90 mmHg Respiratory Rate: 20 breaths per minute Pulse Oximetry: 99% on RA Weight: 165 lbs / 75 kg Height: 74 inches / 188 cm HPI: Mr. Jianquan Zhang is a 31 y/o male who presents with a complaint of right hand pain after punching a wall last night. Pt admits that this occurred when he got upset last night in response to losing a basketball game. Pt was leaving the basketball court and punched a wall in the locker room. He denies fighting with any people or punching anything other than the wall. He noted immediate pain, deformity, and difficulty moving digits 3, 4, and 5 due to pain, and could not close his fist (also due to pain). The pain is most notable over the 5th digit knuckle and has been constant since onset. Pt reports that his symptoms have worsened significantly since onset. Pt reports also now having swelling and bruising of the affected area. The pain is worse with attempts to make a fist, flexing or extending digits 3, 4, or 5. Pt took acetaminophen 500mg this morning with minimal relief of the pain. Pt rates pain as 9/10 currently. Additional associated symptoms include tenderness to palpation of the 3rd, 4th, and 5th digits knuckles, tingling and decreased sensation of the right hand 5th finger distally, nausea due to pain, and small superficial abrasions over the right hand lateral knuckles. No bleeding currently. No loss of ROM at the wrist, elbow, or other proximal joint of the right arm. No other injuries reported. Pt denies prior injury to the affected hand. Pt admits to being right-handed and plays guitar. Pt reports he thought the pain would get better after sleeping it off, but admits symptoms are now worse since the injury occurred. Past Medical History (PMHx): Illnesses/Injuries: Generalized anxiety disorder (diagnosed age 19) Gastric ulcer with bleeding and known H. pylori infection (both were diagnosed and treated 3 years ago at age 28) ACL tear of L knee, sustained from playing basketball (at age 29) Hospitalizations: Only for mentioned surgical procedure below; none otherwise Surgical History: Left knee ACL reconstruction (repair) via arthroscopy (age 29) Screening/Preventive History: Pt is up-to-date on all vaccinations and preventative screenings, including Tdap/Tetanus (last received at age 30). Medications (Prescription, Over the Counter, Supplements): -Escitalopram 10mg PO daily -Omeprazole 20mg PO daily -Tylenol 500mg as needed for pain, last dose 10 AM today. Allergies (e.g. environmental, food, medication and reaction): Penicillins (rash, difficulty breathing) NSAIDs (pt was previously advised to avoid NSAIDs due hx of gastric ulcer and bleed) Family Medical History: Mother (alive, age 59) - has history of HTN Father (alive, age 60) - has history of Diabetes Mellitus Type 2 Sister (alive, 29) – healthy, no known medical hx No children No genetic disorders known in family Social History: Substance Use / Alcohol Use: No tobacco or substance abuse/use. Pt reports drinking 1-2 alcoholic drinks per weekend (usually wine) Diet: No special diet reported Home Environment: Lives with his girlfriend in an apartment just outside of Temecula Occupation: Chef at a winery in Temecula Leisure Activities: Pt likes to play basketball on weekends, trail run, and walk his dog Exercise: Active 3-4x per week, often playing basketball or running Sleep: 6-7 hours per night Religion: Christian Sexual: Sexually active only with his girlfriend, uses condoms as birth control method ROS (Review of Systems): General: No weight loss, fever/chills, or night sweats. Skin: See HPI. Small minor abrasions to right hand knuckles 3, 4, and 5 with ecchymoses reported in this area as well. HEENT: No headache, neck pain/stiffness, no sore throat. No vision changes or double vision. Respiratory: No cough, shortness of breath or wheezing. Cardiovascular: No chest pain or palpitations. Gastrointestinal: See HPI. +Nausea without vomiting. No diarrhea or constipation. No reported abdominal pain or flank pain Musculoskeletal: See HPI. No back pain or neck pain reported. No other injuries reported. Psychiatric: No thoughts of self-harm. Hematologic: No known hx of easy bruising/bleeding, or gum bleeding. Neurologic: See HPI. No dizziness, headache, confusion, or disorientation. Physical Exam: General: Pt appears uncomfortable. Pt is a WDWN male otherwise. Pt is cooperative, alert and oriented appropriately. Skin: Superficial abrasions noted on right hand knuckles 3, 4, and 5. There are no lacerations or areas of active bleeding noted. Ecchymosis is noted at the base of digits 4, and 5 on the palmar aspect and some on the dorsal aspect of the hand as well. Otherwise, the warm skin, no rashes, normal turgor, no pallor or cyanosis throughout, including distal B/L LEs. Head: Normocephalic, atraumatic. No obvious signs of head trauma on exam such as contusion, abrasion, bruising, or laceration. Eyes: PEERLA B/L, EOMI B/L, sclera anicteric, conjunctiva clear. Neck: Non-tender, c-spine ROM intact, no midline TTP, step-offs, or deformity. No visible skin changes, contusion, or abrasion. Pulmonary: Lungs clear to auscultation B/L, no crackles, wheezes, or rhonchi. Cardiac: Regular rate and rhythm. No murmurs, gallops, or rubs. Normal S1 and S2 otherwise. Peripheral Vascular: Capillary refill less than 2 seconds throughout distal extremities bilaterally. Peripheral pulses full and equal bilaterally, most notably 2+ radial pulses B/L with normal capillary refill of left hand (as well as R hand) Abdomen: Soft, non-distended, non-tender. Normoactive BS presents in all 4 quadrants. Rectal: Deferred GU: Deferred MSK: There appears to be deformity to the 5th metacarpal with obvious misalignment of the distal aspect on palpation. There is loss of the knuckle prominence of the 5th digit when the dorsum of the hand is examined and compared to the opposite hand. Pt cannot fully make a fist, nor abduct/adduct the fingers due to pain. There is a loss of 5th digit knuckle prominence persisting on attempts to make a fist. ROM of index and middle fingers appear WNL, but cannot be assessed in digits 4 and 5 due to pain. Notable tenderness to palpation of the 5th digit at the metacarpal-phalangeal joint and mid-metacarpal area. Thumb opposition/reposition is intact when the thumb is assessed alone, but pt cannot bring the 5th digit towards the thumb. The R wrist, elbow, and shoulder ROM appears intact. Left upper extremity appears without injury, deformity, or discoloration. ROM intact at all joints. B/L lower extremities appear without evidence of contusion, deformity, or swelling. Neuro: Pt is AAOX4. On grip strength and flexion/extension/abduction/adduction exam, pt unable to complete this on the right hand due to pain. Left hand WNL (5/5). Strength is 5/5 in B/L thumbs, wrists, elbows, shoulder joints. On sensation assessment, pt reports decreased sensation to the distal 5th finger with all other fingers intact B/L. CN 2-12 intact. Gait normal and without ataxia. Reflexes 2+ in all extremities distally. No tremor or seizure activity noted. Psychiatric: Appropriate mood and affect for situation Interventions completed so far in the ER: -20 gauge IV placed in left arm -Ice applied to the affected hand briefly for pain relief -Right hand abrasions were irrigated, cleaned, and superficial bandages (band-aid) placed -5mg oxycodone and 1000mg acetaminophen were both given once by mouth (2 hours ago, on patient’s initial arrival to the ER) -Imaging completed as noted below Diagnostic Imaging: Interpretation: “This right hand x-ray series reveals an oblique fracture of the neck of the 5th metacarpal. There is noted palmar angulation of the distal fracture fragment of approximately 45 degrees, as well as 3mm of inferior-medial displacement of the distal fracture fragment. Approximately 10 degrees of rotation is also suspected of the distal fracture fragment. There appears to be a small additional comminuted fragment piece at the base of the main distal fracture fragment. There is no intra-articular extension of the fracture. Diffuse soft tissue swelling of the palm noted. Findings are consistent with a Boxer’s fracture.” The following additional radiographs were obtained in the ER: -AP/lateral Right arm ulna/radius (forearm) x-ray - Results: unremarkable, no acute injury, dislocation, or fracture Laboratory Diagnostics: None obtained ***END OF CASE INFORMATION***