NUR 532 SHADOW HEALTH Conditions of the Musculoskeletal and Neurovascular Systems
10/21/2020 Conditions of the Musculoskeletal and Neurovascular Systems
... [Show More] | Completed | Shadow Health
Conditions of the Musculoskeletal and Neurovascular Systems Results | Completed
Primary Care Nursing - FNP III - Advanced Diagnostics Content - September 2020, NUR 532
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Subjective Data Collection: 20 of 22 (90.9%)
Confirmed Guardian's Relationship
Chief Complaint
History of Present Illness
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Lab Pass (/assignment_attempts//lab_pass.p
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Differential Selection
Test Selection
Test Linking
Test Review
Final Diagnosis
Self-Reflection
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Category Scored Items
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of a strong, thorough interview with this patient.
Patient Data
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A combination of open and closed questions will yield
better patient data. The following details are facts of t
patient's case.
Establish Relationship Ned reports he is Chelsea's guardian
Chelsea reports Ned is her guardian
Established Chief Complaint Patient reports left knee pain after a fall
Guardian reports patient has been complaining of
knee pain for "a few weeks"
Asked about previous injuries Patient denies previous injury
Guardian denies previous injury
Asked about mechanism of injury Patient denies landing on head
Patient denies losing consciousness
Patient reports falling two or three feet
Patient reports horse was standing still
Patient reports blood glucose level was normal
after fall
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10/21/2020 Conditions of the Musculoskeletal and Neurovascular Systems | Completed | Shadow Health
Social History
Asked about onset Patient reports mild pain on activity started two
weeks ago
Patient reports severe pain started two days ago
after a fall
Guardian reports noticing patient's increase in pain
after the fall two days ago
Asked about location Patient reports pain located at anterior proximal
tibia
Asked about duration Patient reports mild pain ending shortly after
activity stops
Patient reports severe pain after fall improved the
day after
Asked about characteristics Patient reports mild pain on activity is dull
Patient reports severe pain after the fall was
throbbing
Asked about aggravating factors Patient reports walking up steps aggravates pain
Patient reports kneeling aggravates pain
Patient reports mounting and dismounting a horse
aggravates pain
Guardian confirms noticing the patient's pain after
physical activity
Asked about relieving factors Patient reports rest relieves pain
Patient denies using ice pack
Guardian reports patient refusing to use ice pack
Guardian reports acetaminophen was not effective
Asked about timing Patient denies the pain being worse or better at
certain times of the day
Guardian confirms the pain doesn't seem worse or
better at certain times of the day
Asked about severity Patient reports mild pain on activity is
"uncomfortable"
Patient reports severe pain after the fall was "really
really bad"
Asked about activities of daily living Patient reports discomfort putting on pants and
boots
Guardian reports patient's discomfort while putting
on boots
Asked about social history Patient reports all her friends are girls
Patient reports having a close group of friends
Patient reports being afraid of having her horse
taken away
Guardian reports that patient is well socialized
This study source was downloaded by from CourseH on 08-29-2021 07:27:13 GMT -05:00
This study resource was
shared via CourseH
10/21/2020 Conditions of the Musculoskeletal and Neurovascular Systems | Completed | Shadow Health
Review of Systems
Family History
Past Medical History
Asked about sports safety Denies wearing a helmet because of peer
pressure
Asked about musculoskeletal Reports pain with ambulation in the day after the
fall
Denies pain with ambulation prior to the fall
Reports full range of motion
Reports pain within certain range of movements
Reports being able to bear full weight on leg
Asked about neurological Patient denies abnormal gait
Guardian denies noticing abnormal gait
Patient denies numbness and tingling
Patient denies weakness
Guardian denies noticing weakness
Asked about cardiovascular Patient denies swelling in lower extremities
Patient denies ecchymosis in lower extremities
Patient denies palpitations
Asked about hematologic Patient denies recurrent or easy bruising
Guardian denies noticing recurrent or easy
bruising
Asked about integumentary Patient denies itching, rash, or lesions
Guardian denies noticing itching, rash, or lesions
Asked about family history Guardian denies family history of musculoskeletal
disease
Guardian denies family history of neurological
disease
Asked about type 1 diabetes Patient reports full treatment adherence
Patient denies diabetes symptoms
Guardian confirms patient is adherent
Guardian denies noticing diabetes symptoms
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