Documentation Of Problem-Based Assessment Of The Musc 956923

Question

Documentation of problem based assessment of the musculoskeletal system. Provide a comprehensive report documenting a problem-based subjective and objective assessment of the musculoskeletal system. The report should include the following components: Subjective: Collect and document the patient's biographic data, medications, allergies, and symptoms. Use the PQRSTU framework to analyze symptoms, ensuring detailed descriptions of the patient's complaints. Objective: Record thorough assessment findings for the musculoskeletal system, including inspection, palpation, range of motion, strength testing, and any abnormal findings. Avoid bias and vague descriptors such as "normal" or "appropriate." Actual or potential risk factors: Identify and describe one or two significant risk factors for the patient based on the assessment findings, providing explanations for their relevance. The documentation should follow standard American English conventions, with correct grammar and punctuation. It should effectively demonstrate the assessment skills related to the skin, hair, nails, and musculoskeletal system, as specified in Course Competency.

Dr. Jack HW Helper · Accepted Answer

Patient Name: Jane Doe Age: 45 years Gender: Female Date of Assessment: March 15, 2024 Subjective Jane Doe, a 45-year-old woman, presented with complaints of persistent right ankle pain that began approximately two weeks prior. She described the pain as a dull ache that intensifies after prolonged walking or standing. She reported swelling around the ankle, difficulty bearing weight, and occasional stiffness, especially in the mornings lasting about 30 minutes. Jane has no known allergies but is currently taking antihypertensive medication. Her past medical history includes osteoarthritis and hypertension. Using the PQRSTU framework, her symptoms are characterized as follows: P (Provoking/Palliative): Pain worsens with activity, relieved slightly with rest. Q (Quality): Dull, aching sensation. R (Region/Radiation): Located over the lateral aspect of the ankle; does not radiate. S (Severity): Rated 6 out of 10 on the pain scale. T (Timing): Symptoms persist for two weeks, worsened with activity, improved with rest. U (Understanding): Patient feels the pain may stem from a previous ankle sprain, which she reports as recent but unclear if it directly relates to current symptoms. Objective The physical examination of the musculoskeletal system revealed the following findings: Inspection: Notable swelling and slight erythema over the lateral malleolus. Skin appears intact, without bruising or open wounds. Palpation: Tenderness upon palpation over the lateral ligament complex. Mild warmth noted but no crepitus. Range of Motion (ROM): Active dorsiflexion and plantarflexion are limited due to pain, with dorsiflexion restricted to 10 degrees from normal (approximately 20 degrees). Plantarflexion is limited to 40 degrees from normal (about 50 degrees). Strength Testing: Dorsiflexion and eversion strength are 4/5 compared to the contralateral limb, indicating slight weakness. Special Tests: Anterior drawer and talar tilt tests are positive, suggesting ligament instability. No

Documentation Of Problem-Based Assessment Of The Musc 956923

Documentation of problem based assessment of the musculoskeletal system.

Paper For Above instruction

Subjective

Objective

Risk Factors

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