A Step-by-Step Guide to the Musculoskeletal Exam
Ms. Jones’ musculoskeletal exam went well because she was able to answer all questions correctly, which aided my data collection process (Bickley, 2013). Her complaint was that the pain she was experiencing was caused by lifting a box three days prior to her visit to the clinic (Alexander, Aslam, & Marino, 2017). I was impressed by the patient’s responses to my questions, and she boosted my morale and confidence in working with Shadow Health. The musculoskeletal exam is important for determining how the structures will aid in recognizing joint alignments and appearance. As a result, it aids in identifying the fundamental abnormalities (Bickley, 2013). The neurological exam, on the other hand, seeks to assess a person’s nervous system.
The musculoskeletal exam went relatively well, but there was a problem with missing questions as well as others that Ms. Jones was unable to answer. In my next assessment, I hope to improve the questions I ask my patient and to try to think of appropriate questions (Alexander et al., 2017). Concerning the neurological findings, the recordings did not correspond to the questions I posed to Ms. Jones. Since I’ve gained more knowledge, I’m hoping to improve my skills in the next assessment. She was diagnosed with type 2 diabetes and had a blood pressure of 141/80 (Gross, Fetto, & Rosen, 2015). She is also obese and was a patient receiving treatment for abdominal pain. Her main complaint, however, was that she had been experiencing back pain for three days prior to visiting the clinic. Her pain worsens when she sits but subsides when she lies down (Gross et al., 2015).
The question of what her main complaint was and why she had decided to visit the clinic yielded a lot of information. Concerning the neurologic aspect, I narrowed it down to asking why she was visiting the facility as well as the main complaints she had raised, which led to other questions (Alexander et al., 2017). Ideally, all of the information she presented enabled me to engage in a series of thoughts that, over time, assisted me in developing a plan. Although X-rays and MRIs are useful in musculoskeletal diagnosis, I would first educate her about these tests (Bickley, 2013). I would recommend monofilaments or an x-ray for the neurological test. Some musculoskeletal differential diagnoses include inflammation and muscle strain, while neurological diagnoses include neck soreness and post-traumatic headache.
Following a thorough examination of Ms. Jones, the musculoskeletal findings revealed that while she was lifting the box, her backbone may have been injured; therefore, I would recommend using cold packs to relieve pain and heat packs to reduce inflammation (Gross et al., 2015). I would also advise her to keep taking over-the-counter anti-inflammatory medications. I would also advise her to resume light exercise once her symptoms have subsided (Gross et al., 2015). Her head should be raised when she goes to bed for system reduction and safety. However, if her symptoms persist, I would advise her to seek medical attention. In terms of neurologic findings, Ms. Jones was diagnosed with severe headaches (Bickley, 2013). As a result, she was advised to take ibuprofen with her meals. She was also instructed to apply ice at least three times per day. Changes in hearing or consciousness, vision, tingling, or numbness were also discovered (Alexander et al., 2017).
In terms of musculoskeletal pain, I would not recommend medication because anti-inflammatory medications and other over-the-counter medications are effective (Gross et al., 2015). In terms of neurological issues, I would advise her to take ibuprofen to help with pain or inflammation. I felt confident throughout the entire interviewing process while conducting the musculoskeletal exam, and I was able to sharpen my thinking skills from the various choices I had made (Bickley, 2013). I was also able to gain evidence-based practice in patient care.