RU Physical Assessment of The Musculoskeletal System Question

History and Physical Assessment of the Musculoskeletal System

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Examiner:

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Date:

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Biographical Data:

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Patient: Age:

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Reason for visit:

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Health History (Subjective)

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• Any pain in the joints?
• Any stiffness in the joints?
• Any swelling/heat/redness in the joints?
• Any limitation of movement?
• Any muscle pain or cramping?
• Any deformity of bone or joint?
• Any accidents or trauma to bones or joints?
• Ever had back pain?
• Any problems with ADLs (activities of daily living)? Bathing, dressing, toileting, grooming, eating, mobility, or communicating?

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Physical Examination (Objective)

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• Cervical spineInspect size, contour, deformitiesPalpate for temperature, pain, swelling, or massActive range of motion
• ShouldersInspect size, contour, deformitiesPalpate for temperature, pain, swelling, or massActive range of motion
• ElbowsInspect size, contour, deformitiesPalpate for temperature, pain, swelling, or massActive range of motion
• Wrists and handsInspect size, contour, deformitiesPalpate for temperature, pain, swelling, or massActive range of motion
• HipsInspect size, contour, deformitiesPalpate for temperature, pain, swelling, or massActive range of motion
• KneesInspect size, contour, deformitiesPalpate for temperature, pain, swelling, or massActive range of motion
• Ankles and feetInspect size, contour, deformitiesPalpate for temperature, pain, swelling, or massActive range of motion
• SpineInspect for straight spinous processesInspect equal horizontal positions for shoulders, scapulae, iliac crestsInspect for equal spaces between arms and lateral thoraxInspect for knees and feet aligning with trunk, point forwardFrom side, note curvature: cervical, thoracic, lumbarPalpate spinous processesActive range of motion
• Functional AssessmentWalk (with shoes)Perform KATZ ADL’s assessmentPerform Lawton IADL’s assessmentPick up object from floorPerform TUG test

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i.Flexion, extension, lateral bending right and left, right and left rotation

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i.Flexion, extension, abduction, adduction, internal rotation, external rotation

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i.Flexion, extension, supination, pronation

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i.Wrist extension, flexion

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ii.Finger estension, flexion

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iii.Ulnar deviation, radial deviation

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iv.Fingers spread, make fist

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v.Touch thumb to each finger

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i.Extension, flexion, external rotation, internal rotation, abduction, adduction

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i.Flexion, extension, walk

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i.Dorsiflexion, plantar flexion, inversion, eversion

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i.Flexion, extension, lateral bending left and right, rotation right and left

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Assessment Write-up

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Subjective Data

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Summarize your subjective data in narrative format with complete sentences.

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Objective Data

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Summarize your physical assessment findings here in narrative format with complete sentences. Be descriptive and include each part of the assessment. Include scores of functional assessments.

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Risk Factors and Plan

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Identify two risk factors for your patient from your assessment above. Tell me why you chose them and why they are significant. Then come up with a plan for improvement for your patient. This can just be a couple sentences.

History and Physical Assessment of the Musculoskeletal System
Examiner:
Date:
Biographical Data:
Patient:
Age:
Reason for visit:
Health History (Subjective)
1. Any pain in the joints?
2. Any stiffness in the joints?
3. Any swelling/heat/redness in the joints?
4. Any limitation of movement?
5. Any muscle pain or cramping?
6. Any deformity of bone or joint?
7. Any accidents or trauma to bones or joints?
8. Ever had back pain?
9. Any problems with ADLs (activities of daily living)? Bathing, dressing, toileting,
grooming, eating, mobility, or communicating?
Physical Examination (Objective)
A. Cervical spine
a. Inspect size, contour, deformities
b. Palpate for temperature, pain, swelling, or mass
c. Active range of motion
i. Flexion, extension, lateral bending right and left, right and left rotation
B. Shoulders
a. Inspect size, contour, deformities
b. Palpate for temperature, pain, swelling, or mass
c. Active range of motion
i. Flexion, extension, abduction, adduction, internal rotation, external
rotation
C. Elbows
a. Inspect size, contour, deformities
b. Palpate for temperature, pain, swelling, or mass
c. Active range of motion
i. Flexion, extension, supination, pronation
D. Wrists and hands
a. Inspect size, contour, deformities
b. Palpate for temperature, pain, swelling, or mass
c. Active range of motion
i. Wrist extension, flexion
ii. Finger estension, flexion
iii. Ulnar deviation, radial deviation
iv. Fingers spread, make fist
v. Touch thumb to each finger
E. Hips
a. Inspect size, contour, deformities
b. Palpate for temperature, pain, swelling, or mass
c. Active range of motion
i. Extension, flexion, external rotation, internal rotation, abduction,
adduction
F. Knees
a. Inspect size, contour, deformities
b. Palpate for temperature, pain, swelling, or mass
c. Active range of motion
i. Flexion, extension, walk
G. Ankles and feet
a. Inspect size, contour, deformities
b. Palpate for temperature, pain, swelling, or mass
c. Active range of motion
i. Dorsiflexion, plantar flexion, inversion, eversion
H. Spine
a. Inspect for straight spinous processes
b. Inspect equal horizontal positions for shoulders, scapulae, iliac crests
c. Inspect for equal spaces between arms and lateral thorax
d. Inspect for knees and feet aligning with trunk, point forward
e. From side, note curvature: cervical, thoracic, lumbar
f. Palpate spinous processes
g. Active range of motion
i. Flexion, extension, lateral bending left and right, rotation right and left
I. Functional Assessment
a. Walk (with shoes)
b. Perform KATZ ADL’s assessment
c. Perform Lawton IADL’s assessment
d. Pick up object from floor
e. Perform TUG test
Assessment Write-up
Subjective Data
Summarize your subjective data in narrative format with complete sentences.
Objective Data
Summarize your physical assessment findings here in narrative format with complete
sentences. Be descriptive and include each part of the assessment. Include scores of functional
assessments.
Risk Factors and Plan
Identify two risk factors for your patient from your assessment above. Tell me why you
chose them and why they are significant. Then come up with a plan for improvement for your
patient. This can just be a couple sentences.
Title:
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.
Course Competency:
Demonstrate physical examination skills of the skin, hair, nails, and musculoskeletal system.
Instructions:
Content: Use of three sections:
o
o
o
Subjective
Objective
Actual or potential risk factors for the client based on the assessment findings
with description or reason for selection of them.
Format:
•
Standard American English (correct grammar, punctuation, etc.)
Resources:
Chapter 5: SOAP Notes: The subjective and objective portion only
Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Retrieved from
http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&d
b=nlebk&AN=495456&site=eds-live&ebv=EB&ppid=pp_91
Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30. Retrieved
from
http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&d
b=rzh&AN=107055742&site=eds-live
Documentation Grading Rubric- 10 possible points
Levels of Achievement
Criteria
Subjective
(4 Pts)
Emerging
Competence
Proficiency
Mastery
Missing components
such as biographic
data, medications, or
allergies. Symptoms
analysis is
incomplete. May
Basic biographic
data provided.
Medications and
allergies included.
Symptoms analysis
incomplete. Lacking
Basic biographic
data provided.
Included list of
medications and
allergies. Symptoms
analysis: PQRSTU
Basic biographic
data provided.
Included list of
medications and
allergies. Symptoms
analysis: PQRSTU
Objective
(4 Pts)
contain objective
data.
detail. No objective
data.
Points: 1
Missing components
of assessment for
particular system.
May contain
subjective data. May
have signs of bias or
explanation of
findings. May have
included words such
as “normal”,
“appropriate”,
“okay”, and “good”.
Points: 1
Actual or
Potential Risk
Factors
(2 pts)
Lists one to two
actual or potential
risk factors for the
client based on the
assessment findings
with no description
or reason for
selection of them.
Failure to provide
any potential or
actual risk factors
will result in zero
points for this
criterion.
Points: 0.5
Points: 2
completed. Lacking
detail. No objective
data. Information is
solely what “client”
provided.
Points: 3
completed. Detailed.
No objective data.
Information is solely
what “client”
provided.
Points: 4
Includes all
components of
assessment for
particular system.
Lacks detail. Uses
words such as
“normal”,
“appropriate”, or
“good”. Contains all
objective
information. May
have signs of bias or
explanation of
findings.
Points: 2
Includes all
components of
assessment for
particular system.
Avoided use of
words such as
“normal”,
“appropriate”, or
“good”. No bias or
explanation for
findings evident
Contains all
objective
information
Points: 3
Includes all
components of
assessment for
particular system.
Detailed information
provided. Avoided
use of words such as
“normal”,
“appropriate”, or
“good”. No bias or
explanation for
findings evident. All
objective
information
Points: 4
Brief description of
one or two actual or
potential risk
factors for the client
based on
assessment findings
with description or
reason for selection
of them.
Limited description
of two actual or
potential risk factors
for the client based
on the assessment
findings with
description or
reason for selection
of them.
Comprehensive,
detailed description
of two actual or
potential risk factors
for the client based
on the assessment
findings with
description or
reason for selection
of them.
Points: 1
Points: 1.5
Points: 2