Course Notes >N304 Subjective/Objective Notes: SO Musculoskeletal. Indiana State University NURS 304

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N304 Subjective/Objective Notes Musculoskeletal Student Name: Hope Kamuwanda Patient Initials: KG Patient Gender: M

Preceptor Name: Kyra McCoy Date of Exam: 3/19/2020 Patient Age: 59

System: Musculoskeletal

S Subjective

Chief Complaint (patient’s own words): “I sometimes get gout flare-ups, but I am doing well right now. I want to help you pass the class.”

History of Present Illness: Client reports history of gout especially in bilateral big toes.

He also reports a history of polio which affected his right leg.

He denies any history of arthritis or osteoporosis. He also reports that he fractured his right tibia and fibula last year but is now healed. Denies any mobility issues r/t to joint pain except when he has gout flare-ups. He denies any history or muscle pain or other problems. Denies any history of bone cancers. Client is permanently disabled and does not work.

Past Medical History: Client reports history of gout and polio. Reports fracture of right tibia and fibula but denies any orthopedic surgeries.

Reports he knows alcohol causes gout flare-ups, but he is not ready to stop drinking. Reports history of chronic pancreatitis, alcoholic liver, and Stage 3 chronic kidney disease, type 2 diabetes mellitus for 26 years. He also reports history of retinitis pigmentosa in both eyes, and high cholesterol. He denies any family history of joint problems or bone cancers “as far as I know.”

Medications: Omeprazole 20mg PO BID – GERD Humalog pen 20 units subq AC – Type 2 DM Lantus pen 30 units subq Hs – Type 2 DM Allopurinol 300mg PO daily - gout Calcitriol 1mg PO daily - Stage III CKD Nortriptyline 75mg PO HS - sleep Colchicine 0.6mg PO daily – gout Creon 12000-38000-60000 units PO AC – chronic pancreatitis Trazodone 200mg PO HS - sleep Tizanidine 2mg PO TID PRN – muscle spasms Pravastatin 40mg PO every evening – high cholesterol

NURS 304 Sp2020 revised 122019 This study source was downloaded by 100000859607764 from CourseHero.com on 01-03-2023 17:50:51 GMT -06:00

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O Objective

Clinical Exam: Neck – no abnormal findings on inspection, strength is 5/5 and ROM is within normal range. Denies any pain on palpation or movement.

Shoulders – adduction, abduction intact, strength 5/5 Arms, wrist, hands – ROM intact, strength 5/5, no abnormal findings on inspection. No pain noted on movement or palpation.

Hips, knees – ROM intact, strength 5/5, there is a swelling behind right knee, but no abnormal finding on left knee or hips. Denies any pain on palpation of swelling.

Ankles – swollen but no pain on palpation. ROM intact, strength 5/5.

Feet – bilateral big toes look swollen, but client denies any pain when weight bearing or palpation. Normal curvature bilaterally. When standing, the right leg appears shorter than the left leg aeb client standing on tiptoe with right leg.

Strength is 5/5 bilaterally.

NURS 304 Sp2020 revised 122019 This study source was downloaded by 100000859607764 from CourseHero.com on 01-03-2023 17:50:51 GMT -06:00

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