By Editorial Team Jan 14, 2022
You will perform a history of a musculoskeletal problem one you have experienced and perform an assessment of the musculoskeletal system. You will document your subjective and objective findings, identify actual or potential risks. Your subjective portion of the documentation should briefly describe your “client”. Your client information is noted below.
Client Name: Mackenzie Carlson
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, a notable limp is noted when the client walks favoring the affected extremity. She states 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.” When you examine the ankle the outer aspect of the malleolus is swollen and reddened with 2+ edema noted to the area, pedal pulses are palpable and strong.
Documentation of problem based assessment of the musculoskeletal system.
Purpose of Assignment:
Learning the required components of documenting a problem based subjective and objective assessment of musculoskeletal system. Identify abnormal findings.
Demonstrate physical examination skills of the skin, hair, nails, and musculoskeletal system.
Content: Use of three sections:
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