Patient Case For Musculoskeletal
You will perform a history of a musculoskeletal problem that your instructor has provided you or one that you have experienced and perform an assessment of the musculoskeletal system. You will document your subjective and objective findings, identify actual or potential risks, and submit this in a Word document to the drop box provided. Your subjective portion of the documentation should briefly describe your “client”. For example, “This client is a 23-year-old white female complaining of a painful, swollen ankle. States that she stepped ‘funny’ off a step two days ago and thinks she heard a ripping sound. She takes no medications and has no allergies. The client reports pain as 5/10 with sharp twinges when trying to walk, resting and ice decreases pain to 2/10 aching. Pain is primarily in the outer aspect of ankle and foot. Has no prior injury to this area. No significant past medical history.” In terms of your objective findings, remember to only record what you have assessed. Do not make a diagnosis or state the cause of a finding. You are not coming to any conclusions within your documentation. When your documentation is complete, you will note any findings that were abnormal.
You will submit this documentation as a Word document to the drop box provided.
Musculoskeletal Patient Case
Patient Case- you should embellish and add additional details to the patient case as needed to reflect full documentation of a musculoskeletal problem, but please use the following basic information to document about your patient:
Background info (Subjective Data)
Mrs. Bluejay is an 80-year-old Native American female who recently fell on her right hip, requiring hospitalization. She has been in the skilled nursing facility for 10 days for rehabilitation with physical therapy.
Current medications include alendronate sodium (Fosamax) for osteoarthritis. Supplements are a multivitamin, vitamin D, calcium, and magnesium.
She has no known food, drug, or environmental allergies.
Past medical history: arthritis
HPI: She is currently in pain. She reports pain: 4/10 in her right hip from the fall. Ask her more OLDCARTS about her current symptoms and make up what her answers may be.
Physical Examination (Objective Data)
Vital Signs: Oral Temp 36.6 C, HR 82 BPM, RR 18, and BP 122/64.
Inspection: mild kyphosis, right hip limited range of motion. Document rest of inspection as a normal or expected finding.
Palpation: Tenderness of right hip. Muscle strength 3/5 of right hip. Document other extremities and palpation as a normal or expected finding.
