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NURS 6512N: Advanced Health Assessment and Diagnostic Reasoning Week 8: Assessment of the Musculoskeletal SystemAssessing Muscoskeletal PainScenario 2: Patient Initials: MHAge:46yoGender: Female Ethnicity: CaucasianSubjective Data:CC:Bilateral ankle pain.HPI: MH is a 46-year-old Caucasian female who presents today with bilateral ankle pain, with worse pain in the right ankle. The pain initiated after playing soccer over the weekend when she heard a “pop”. She reports that she can bear weight but finds it to be uncomfortable.Current Medications: NoneAllergies:NKDAPMHx: NoneSoc Hx: Denies tobacco abuse. Denies ETOH abuse. Denies Illicit drug abuse. Single.Fam Hx: NoneROS: GENERAL--AOX4. Calm Cooperative follows commands. Denies weight loss, fever, or chills.HEENT--Head: Denies headache. No loss of consciousness. No head trauma. Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears: No hearing loss, tinnitus, or drainage. Nose: Denies runny nose or congestion. Throat: Denies sore throat. Speech is clear.
Neck--Denies any neck tenderness. No thyromegaly. No carotid bruits. No masses or tracheal deviation noted.SKIN– No rash or itching. No excoriation.CARDIOVASCULAR– No chest pain, No palpitations, No edema. RESPIRATORY– No shortness of breath, No dyspnea on excretion, No cough.GASTROINTESTINAL--No anorexia, nausea, vomiting or diarrhea. No abdominal pain. GENITOURINARY--No burning on urination. Denies frequency, hesitancy, dysuria, or incontinence.NEUROLOGICAL– No headache. No dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.MUSCULOSKELETAL– No arthralgia/myalgia, no arthritis or gout. + limited range of motionwith pain on dorsiflexion in right ankle, No history of fractures.