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Assessing Musculoskeletal System

Assessing Musculoskeletal System

Assessing Musculoskeletal System

QUESTION
The goal of this assignment is to practice writing a SOAP Note for a sick or episodic visit related to the focus system(s) reviewed in the previous week’s learning materials. If there is not an opportunity to see a patient with a chief complaint in the focus system(s), complete a history and physical examination of the focus system on another patient seen in the clinical practicum site. Review the SOAP Note Rubric and submit your own note. Do not submit the preceptor’s note or other documentation from the patient’s record. PLEASE FOLLOW RUBRIC FOR NOTE
must have a diagnosis/plan + 2 differential diagnosis also. Thank you kindly.

Assessing Musculoskeletal System

ANSWER

Assessing Musculoskeletal System

Student Names
Professor’s Name
Institution Affiliation
Course Name: Course Code
Date

Episodic Focused Notes on a Patient with Knee Pain
Patient Information
A.W. is a 28-year-old African American male: Referral: none Source: Patient.
Chief Complaint: Severe knee pain
History of presenting illness (HPI)
The patient presents complaints of severe crunchy pain on both knees which began early this month; A.W describes a ‘catchy’ feeling under the patella sometimes when both knees click. He reports that the pain accelerates when his walking or doing his morning jog. A.W also adds that the pain intensified when he went to the gym this morning. He reports that the pain is on a scale of 6-10 and has forced him to stop attending basketball practices. The patient admits to the use of pain relievers in the past week, and the consumption of aspirin for headaches.
Past Medical History (PMH)
The patient denies any history of cancer, hips dysplasia, or heart attack cases. A positive history of Diabetes: and cases of depression: Reports no cases of allergies related to penicillin.
Social History (SH)
Patients assert the use of energy drinks. No report on alcohol or tobacco abuse. The patient further denies the use of illicit drugs and confirms engagement in regular body exercises. He also reports that he plays basketball with his college friends.
Family History (FH)
The maternal grandfather suffers from osteoarthritis. Father suffers from constant back pain and has been on medication. The present history of Rheumatologic joint pains among extended relatives.
Review of Systems (ROS)
General: Negative for fevers and fatigue, sleep disturbances due to pain. Musculoskeletal: No muscle pain, joint stiffness or swellings, no deformities or trauma, limited range of motion on the affected knee. Neck pain: no abnormalities or Edema (Lewis, et al, 2019).
Objective: Physical Assessment
Patellofemoral pain. General- patient appears to have no fever. Musculoskeletal- coordinated gait with the ability to bear weight, smooth, no heat, or stiffness (Ball, et.al,2019). Joints and muscles symmetrical: Normal spine curvature.
Differential Diagnosis
X-ray to determine the cause of knee pain and check on whether the knee cap is in the right position. Patella tendonitis inclusive of visiting a physical therapist (Dains, Baumann& Scheibel, 2015).

References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2015). Advanced health assessment and clinical diagnosis in primary care.
Lewis, R., Gómez Álvarez, C. B., Rayman, M., Lanham-New, S., Woolf, A., & Mobasheri, A. (2019). Strategies for optimising musculoskeletal health in the 21st century. BMC Musculoskeletal Disorders, 20(1). https://doi.org/10.1186/s12891-019-2510-7

Assessing Musculoskeletal System

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