Documentation of problem based assessment of the musculoskeletal ✓ Solved

Documentation of problem based assessment of the musculoskeletal

Document a problem-based assessment of the musculoskeletal system. Use three sections:

  • Subjective

  • Objective

  • Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Format in Standard American English (correct grammar, punctuation, etc.).

Paper For Above Instructions

The musculoskeletal system is an intricate structure comprising bones, muscles, cartilage, tendons, and ligaments that provide support, stability, and mobility to the human body. A thorough understanding and documentation of the musculoskeletal assessment is vital for ensuring proper diagnosis and treatment. This paper will follow a structured approach using the subjective and objective sections to document findings, as well as identifying actual or potential risk factors based on the assessment.

Subjective Assessment

During the subjective assessment, the patient, a 45-year-old female, reported experiencing intermittent pain in her right knee for the past two months. She described the pain as a dull ache that intensifies during activities such as climbing stairs or prolonged sitting. The patient also reported experiencing stiffness in the joint upon waking in the morning, which lasts for about 30 minutes. She has a history of osteoarthritis, which she has managed with over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs). The patient denies any recent trauma to the knee but mentions a family history of arthritis. Allergies include ibuprofen, leading her to avoid it, and she currently takes acetaminophen as needed. The patient rates her pain as a 6 on a scale of 1 to 10 during activity and a 3 at rest.

Objective Assessment

The objective assessment begins with the inspection of the knee joint. There is visible swelling on the medial aspect of the right knee, and the range of motion is limited to approximately 90 degrees during flexion. Upon palpation, mild tenderness is noted around the joint line. No deformities or crepitus are present. The patient showed a negative Lachman test, indicating no significant anterior cruciate ligament (ACL) instability, but a McMurray test elicited pain, suggesting a possible meniscal tear. Muscle strength graded at 4/5 for knee flexion and extension due to pain inhibition. Gait was observed to be antalgic, favoring the right knee.

Actual or Potential Risk Factors

Based on the assessment findings, two main actual or potential risk factors are identified:

  • Age-related degeneration: The patient is 45 years old, and with her history of osteoarthritis, there is an increased risk of joint degeneration and exacerbation of symptoms, particularly with activities that require joint loading (Sullivan, 2012).

  • Weight management: The patient’s BMI is above the normal range, which can exacerbate knee symptoms due to increased mechanical stress on the joint (Smith, 2001). Weight reduction could help improve symptoms and functionality.

Conclusion

In conclusion, this documentation serves to provide a structured assessment of the musculoskeletal system focusing on the knee. Accurate subjective reporting combined with objective findings aids in developing a comprehensive view of the patient's condition. Identifying actual and potential risk factors enables healthcare professionals to develop targeted interventions for effective management of musculoskeletal disorders.

References

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