COURSE:
PRAC 6531 – Primary Care of Adults Across the Lifespan Practicum
Assignment 2: Episodic Visit; Musculoskeletal Focused Note
For this Assignment, you will work with a patient with a musculoskeletal condition that you examined during the last three weeks. You will complete your third Episodic/Focused Note Template Form for this course where you will gather patient information, relevant diagnostic and treatment information as well as reflect on health promotion and disease prevention.
By Day 7 of Week 9
Submit your Episodic/Focused Note Assignment.
See the weekly Assignment 2 area for details.
SOLUTION
Musculoskeletal Focused Note
Patient Information:
Initials: EM Age: 27 Gender: Female
Race: African-American
Subjective
Chief Complaint: “I have a lot of pain in my lower back and does not seem to go away. It’s very difficult for me to get things done”.
History of Present Illness: A 27 years old female Ms. Emma came to the clinic and complaint of lower back pain which started three days before when she jerked while helping her friend in lifting a large crate. She claimed that she carried many boxes but she did not know which weigh box triggered this pain and discomfort. The discomfort gets worse due to sitting (7/10) and when she lies flat on her back, she feels better (4/10). But the pain and discomfort did not improve in three days. She is experiencing muscle fatigue, incontinence of the bladder, and numbness. She is using OTC Ibuprofen medication after every 5 hours and experiencing relief in symptoms. But today, her discomfort is persisting and interfering in routine activities.
Location: Lower back Onset: three days ago
Character: Difficulty in performing tasks and movement
Associated signs and symptoms: Muscle weakness, incontinence, tingling, numbness.
Exacerbating factors: Sitting for long hours……………………………………..$15