Musculoskeletal System, Hair, Nails, and skin

Musculoskeletal System, Hair, Nails, and skin

Subjective Findings

            The patient is a 50-year-old Caucasian female presenting to the clinic with a history of pain in the left knee for twelve hours. She asserts that the pain was sudden onset, beginning while walking home from the market. She could not continue walking, and she fell on the pavement and the inner part of her left knee suddenly became very painful. She reports that the pain is sharp, non-radiating, and has no specific timing. It is accompanied by swelling, redness, and hotness around the left knee. She also reports that she is unable to walk or stand. It was not associated with bleeding or any fracture. There were no relieving factors, and the pain was aggravated by touching and moving the left knee and attempting to stand. She has not taken any analgesics since then. She is not allergic to any medications. She grades the severity of the pain at a 9 out of 10. There is no history of any previous admissions, transfusions, or surgery. Do you need urgent assignment help ? Get in touch with us at eminencepapers.com. We offer assignment help with high professionalism.

Objective Findings

            On inspection, there were no scars, lacerations, or bleeding on both knees. The left knee was oedematous and erythematous. The gait and the varus deformity were not assessed because the patient was in pain and could not stand. There was an apparent leg discrepancy, with the left leg being shorter than the right. On palpation, the left knee was hot and tender on touch. There was crepitus on the left knee. Both left passive and active ROM was limited. The muscle bulk was normal on both knees, while tone increased on the left knee. Muscle power was at 2. The left popliteal pulse was diminished, while the posterior tibial and dorsalis pedis pulses were present. The knee-jerk reflex was not assessed because the patient was in pain. All the other reflexes were intact.

Actual or Potential Risks

            The patient might appear to be in good health. However, edema might develop because exercise must be restricted to promote healing and surgical intervention of a possible knee injury (Sullivan, 2018). There is a chance that DVT, stiff joints, and osteoarthritis will develop later in life. She may sustain more injuries when trying to repair the damage when walking. By affecting gait, limping can cause discomfort in other surrounding joints, such as the hip and ankle joints. Moreover, because she interferes with her ADL, she might develop psychological trauma (Neri et al., 2019).

References

Neri, T., Myat, D., Beach, A., & Parker, D. A. (2019). Multi ligament knee injury: Injury patterns, outcomes, and gait analysis. Clinics in sports medicine, 38(2), 235-246. https://doi.org/10.1016/j.csm.2018.11.010

Sullivan, D. D. (2018). Guide to clinical documentation. FA Davis.

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Musculoskeletal System, Hair, Nails, and skin

You will perform a history of the hair, nails, skin, and musculoskeletal problems your instructor provided you or one you have experienced and assess 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 thought she heard a ripping sound. She takes no medications and has no allergies. The client reports pain as 5/10 with sharp cramps when trying to walk; resting,g, and ice decrease pain to 2/10 aching. Pain is primarily in the outer aspect of the ankle and foot. Has no prior injury to this area. No significant past medical history.” In terms of your objective findings, remember only to 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 abnormal findings.