Nursing

Thank you so much for receiving my order. This are instructions, 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.

ANSWER

History of Musculoskeletal Problem

Subjective Findings

             A 23-year old patient was presented with a case of right knee pain. He indicates that the pain in his right knee began when he was out for a morning jock. He stripped on an object and feel on the ground injuring his right knee. The pain is currently intense, making it hard to bear weight. He has consumed any pain relievers yet. It has been five hours since the accident happened. The patient has no medication antipathies. He actually scores his agony as 5/10, and the pain does not subsidize in either way. The client does not experience any bleeding, it was just a lump as a result of a hard knock on the ground. The surface of the right knee is mildly red, and there is some warmth when you touch. The patient has had no previous surgical or medical history.

Objective Data

            After doing the analysis, the objective data shows that the patient’s ankles, knees and hips tend to have greatest intact. Nonetheless, the patient has decreased scope of movement in the right knee and ankle due to twisting (Pascoli et al. 2010). On the medial aspect of the leg, there were slight non-pitting edema and erythema. There are 2+ bilateral peripheral pulses in the legs (Pascoli et al. 2010). The skin is tacky to the touch. Due to the discomfort, the gait cannot be assessed.

Risk Factors

            The patient could be in a good condition since there is no daily medication or allergies. Nonetheless, there is a risk of developing deep vein thrombosis (DVT) in the future due to the requirement for decreased exercise to permit for recovery and maybe surgical remedy of a suspected knee injury (Pascoli et al. 2010). The patient is also at risk of developing other injuries due to gradual walking motion. The art of limping can cause pain on other joints by damaging one’s gait.

References

Pascoli, L., Wright, S., McALLISTER, C. A. T. H. E. R. I. N. E., & Rooney, M. (2010). Prospective evaluation of clinical and ultrasound findings in ankle disease in juvenile idiopathic arthritis: importance of ankle ultrasound. The Journal of rheumatology, 37(11), 2409-2414