You will perform a history of a musculoskeletal problem on the client below. You will document your subjective and objective findings, identify actual or potential risks, and submit this in a Word document to the drop box provided. Your subjective portion of the documentation should briefly describe your “client”. In terms of your objective findings, remember to only record what you have assessed. Do not make a diagnosis or state the cause of a finding. You are not coming to any conclusions within your documentation. Your client information is noted below.
Client Name: Mackenzie Carlson
DOB: 10-10-1986
This client is a 37-year-old white female complaining of a
painful, swollen ankle. States that she stepped ‘funny’ off a step two days ago
and thinks she heard a ripping sound. She takes no medications and has no
allergies. The client reports pain as 5/10 with sharp twinges when trying to
walk, a notable limp is noted when the client walks favoring the affected
extremity. She states resting and ice decreases pain to 2/10 aching. Pain is
primarily in the outer aspect of ankle and foot. Has no prior injury to this
area. No significant past medical history. When you examine the ankle the outer
aspect of the malleolus is swollen and reddened with 2+ edema noted to the
area, pedal pulses are palpable and strong.
You will submit this documentation as a Word document to the
drop box provided.
