PRAC 6531 Episodic Visit: Musculoskeletal Focused Note

PRAC 6531 Episodic Visit: Musculoskeletal Focused Note

Musculoskeletal Focused Note

Patient Information:

Initials: S.F.               Age: 19 years old     Sex: Female             Race: Caucasian

S.

CC: “My left ankle has been swollen and painful since yesterday.”

HPI: S.F. is a 19-year-old Caucasian female presenting with left ankle pain and swelling after stepping off a curb awkwardly while jogging yesterday morning. She reports the pain is located on the lateral side of the ankle, with a sharp, throbbing character rated 6/10 in severity. The onset was instantaneous, and she remembers hearing a “pop” at the moment of injury. She applied ice and rested the ankle, but swelling has increased, and she now has difficulty bearing weight. She denies numbness or tingling but reports mild bruising and stiffness. No history of prior ankle injuries. She denies fever, chills, or systemic symptoms. Ibuprofen has provided minimal relief. She is concerned about a possible sprain or fracture and seeks evaluation and pain relief. She is otherwise healthy and active with no significant medical issues. No other joints are affected. No recent travel, tick exposure, or preceding illness.

Current Medications: For pain relief, she takes 400 mg of Ibuprofen every 6 hours. Takes ethinyl estradiol/norgestimate orally every day; no herbal supplements are used.

Allergies: No known drug allergies. Allergic to cats (sneezing, watery eyes). Seasonal pollen allergy (itchy eyes, runny nose). No food allergies.

PMHx: Generally healthy. History of mild seasonal allergies. Immunizations are current; there are no chronic conditions; the latest tetanus booster was given two years ago.

PSHx: Tonsillectomy at age 8. Wisdom tooth extraction at 17. No orthopedic surgeries or hospitalizations. No history of fractures or joint problems.

Soc Hx: College student studying biology; plays intramural soccer and jogs 3–4 times per week. Lives on campus with a roommate. Denies using tobacco products or drugs recreationally. Socially consumes alcohol (1 to 2 beers on weekends). Uses seatbelt regularly and has a working smoke detector in her dorm. Sound social support system from family and friends. Communicates frequently via text but refrains from using the phone while driving.

Fam Hx: Mother has hypertension; father is healthy. No family history of autoimmune or rheumatologic disorders. No significant musculoskeletal conditions in siblings.

 

ROS:

GENERAL: denies night sweats, fever, chills, exhaustion, and recent weight loss.

HEENT: denies sore throats, headaches, visual abnormalities, and hearing loss.

SKIN: denies lesions, rashes, and itching.

CARDIOVASCULAR: denies edema, dizziness, palpitations, or chest pain.

RESPIRATORY: denies hemoptysis, wheezing, coughing, or shortness of breath.

GASTROINTESTINAL: denies diarrhea, constipation, nausea, vomiting, and stomach pain. Intact appetite.

GENITOURINARY: Denies dysuria, urgency, frequency, hematuria, or discharge—last menstrual period 2 weeks ago; regular cycles.

NEUROLOGICAL: denies syncope, headache, tingling, weakness, or dizziness.

MUSCULOSKELETAL: Reports left ankle pain, swelling, bruising, and limited range of motion since injury. Denies back pain, muscle aches, or other joint complaints.

HEMATOLOGICAL: Denies susceptibility to simple bruising or extended bleeding.

LYMPHATICS: No reported enlargement of lymph nodes or history of lymphatic diseases.

PSYCHIATRIC: Denies experiencing anxiety, depression, mood fluctuations, or sleep difficulties.

ENDOCRINOLOGICAL: Denies intolerance to heat or cold, excessive thirst, or polyuria.

ALLERGIES: Denies asthma or eczema. Reports seasonal allergic rhinitis and cat allergy.

O.

Vital Signs: Temp: 98.4°F (36.9°C), BP: 112/70 mmHg, HR: 76 bpm, RR: 16 bpm, Oxygen Saturation: 99% on room air, Ht: 5’6″, Wt: 132 lbs, BMI: 21.3

GENERAL: Alert, cooperative, and in no acute distress. Ambulates with a limp using minimal assistance. Mild discomfort noted when weight-bearing on the left side.

HEENT: Head is atraumatic and normocephalic. The pupils are symmetrical, round, and responsive to light. Extraocular motions are preserved—absence of sinus soreness. Oropharynx is unremarkable—absence of cervical lymphadenopathy.

MUSCULOSKELETAL: Upon examination, the left ankle’s lateral aspect shows ecchymosis and slight edema; there are no visible incisions. Tenderness is palpable above the lateral malleolus and anterior talofibular ligament. No pain over the proximal fibula or medial malleolus. Negative Thompson test. Pain with inversion stress. Mild limitation in dorsiflexion and plantarflexion due to discomfort. Positive anterior drawer test on the left. No signs of deformity. Right ankle normal.

NEUROLOGICAL: Conscious and focused x3. II–XII cranial nerves are unharmed. Pinprick and gentle touch sensations are unaffected on the lower legs and feet. Motor strength 5/5 bilaterally except left ankle, limited by pain. Reflexes 2+ and symmetrical in lower extremities. Negative Babinski.

Diagnostic results: Left ankle X-ray shows no fracture, mild soft-tissue swelling.

A.

Differential Diagnoses:

1. Ankle Sprain – Lateral (S93.401A): Primary diagnosis. Classic signs of a lateral ankle sprain include swelling, bruising, and pain over the anterior talofibular ligament, which is the mechanism of injury (inversion), and a positive anterior drawer test supports this. No fracture is seen on the X-ray, confirming soft tissue involvement (Saki et al., 2020).
2. Ankle Fracture – Lateral Malleolus (S82.64XA): Less likely due to absence of bony tenderness over the fibula and clean X-ray findings. However, it must always be ruled out in acute ankle injuries with swelling and impaired weight-bearing, especially in high-impact or twisting injuries (Cai et al., 2024).
3. Tendon Injury – Peroneal Tendon Strain (S96.812A): Possible due to lateral ankle pain and difficulty with eversion, but less likely as symptoms are consistent with ligamentous—not tendinous—injury. Peroneal strain often presents with more focal tenderness and pain on resisted eversion, which was not reported in this patient (Zhou et al., 2024).

 

• Diagnostics: Left ankle X-ray ordered to rule out fracture; results confirmed soft tissue injury, no bony involvement.
• Pharmacologic Treatment: Administer ibuprofen 400 mg orally every 6 hours as needed for discomfort and inflammation (Dhillon et al., 2023). Informed about gastrointestinal side effects and appropriate dose.
• Nonpharmacologic Treatment: RICE protocol—rest, ice, compression using an elastic bandage, plus elevation for 48 to 72 hours (Fermín et al., 2023).
• Mobility Support: Advised limited weight-bearing for 2–3 days; use of crutches if needed.
• Alternative Therapy: Encouraged gentle ankle ROM exercises after acute phase; consider PT if symptoms persist (Fermín et al., 2023).
• Education: Instructed on injury care, signs of complications (numbness, increased pain), and safe return to activity.
• Follow-Up: Re-evaluation in 1 week or sooner if worsening; earlier referral to orthopedics if no improvement.

Reflection: In a similar evaluation, I would incorporate the early use of functional assessment tools, such as the Ottawa Ankle Rules, to guide imaging decisions more efficiently. I would also emphasize patient education on injury prevention, especially for active young adults like this 19-year-old. Discussing proper footwear, warm-up routines, and ankle-strengthening exercises could reduce recurrence (Fermín et al., 2023). Considering her age and college lifestyle, I would also explore stress management and time constraints that may impact adherence to recovery (Zhang et al., 2023). Her Caucasian background and lack of chronic conditions lower risk, but continued health promotion through physical activity, injury prevention, and safe behaviors remains essential for long-term musculoskeletal wellness.

References

Cai, R., Feng, S., Chen, C., Lu, H., & Xu, H. (2024). Morphological and clinical study of lateral malleolus fractures based on fracture mapping: a retrospective study. Journal of Orthopaedic Surgery and Research, 19(1). https://doi.org/10.1186/s13018-024-05424-1

Dhillon, M. S., Patel, S., & Baburaj, V. (2023). Ankle sprain and chronic lateral ankle instability. Foot and Ankle Clinics, 28(2), 297–307. https://doi.org/10.1016/j.fcl.2022.12.006

Fermín, T. M., Al-Dolaymi, A. A., & D’Hooghe, P. (2023). Acute ankle sprain in elite athletes. Foot and Ankle Clinics, 28(2), 309–320. https://doi.org/10.1016/j.fcl.2022.12.007

Saki, F., Yalfani, A., Fousekis, K., Sodejani, S. H., & Ramezani, F. (2020). Anatomical risk factors of lateral ankle sprain in adolescent athletes: A prospective cohort study. Physical Therapy in Sport, 48, 26–34. https://doi.org/10.1016/j.ptsp.2020.12.009

Zhang, J., Yang, K., Wang, C., Gu, W., Li, X., Fu, S., Song, G., Wang, J., Wu, C., Zhu, H., & Shi, Z. (2023). Risk factors for chronic ankle instability after first episode of lateral ankle sprain: A retrospective analysis of 362 cases. Journal of Sport and Health Science/Journal of Sport and Health Science, 12(5), 606–612. https://doi.org/10.1016/j.jshs.2023.03.005

Zhou, Z., Zhou, H., Jie, T., Xu, D., Teo, E., Wang, M., & Gu, Y. (2024). Analysis of stress response distribution in patients with lateral ankle ligament injuries: a study of neural control strategies utilizing predictive computing models. Frontiers in Physiology, 15. https://doi.org/10.3389/fphys.2024.1438194

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Episodic Visit: Musculoskeletal Focused Note

For this Assignment, you will work with a patient with a musculoskeletal condition that you examined during the last three weeks. You will complete your third  Episodic/Focused Note Template Form for this course where you will gather patient information, relevant diagnostic and treatment information as well as reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, previous medical history (PMH), socio-economic, cultural background, etc. In this week’s Learning Resources, please review the Focused Note resources for guidance on writing Focused Notes.

Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using Turnitin.

Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

Resources

 

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

Learning Resources

Required Readings

• Fowler, G. C. (2020). Pfenninger and Fowler’s procedures for primary care  (4th ed.). Elsevier.
  • Chapter 174, “Shoulder Dislocations” (pp. 1163–1167)
  • Chapter 175, “Ankle and Foot Splinting, Casting, and Taping” (pp. 1168–1175)
  • Chapter 176, “Cast Immobilization and Upper Extremity Splinting” (pp. 1176–1185)
  • Chapter 177, “Knee Braces” (pp. 1186–1192)
  • Chapter 178, “Fracture Care” (pp. 1193–1211)
  • Chapter 180, “Joint and Soft Tissue Aspiration and Injection (Arthrocentesis)” (pp. 1221–1239)
  • Chapter 181, “Trigger-Point Injection” (pp. 1240–1244)
  • Chapter 235, “Principles of X-Ray Interpretation” (pp. 1566–1575)

Practicum Resources

• HSoft Corporation. (2019). Meditrek: Home .Links to an external site. https://edu.meditrek.com/Default.html
  Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.
• Walden University Field Experience. (2019a). Field experience: College of Nursing. Links to an external site. https://academicguides.waldenu.edu/fieldexperience/son/home
• Walden University Field Experience. (2019b). Student practicum resources: NP student orientation. Links to an external site. https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation
• Walden University. (2019). MSN nurse practitioner practicum manual .Links to an external site. https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments
• Document: Episodic/Focused Note Template (Word document)Download Episodic/Focused Note Template (Word document)

To prepare:  

• Use the Episodic/Focused Note Template found in the Learning Resources for this week to complete this assignment.
• Select a patient that you examined during the last three weeks based on musculoskeletal conditions. With this patient in mind, address the following in a Focused Note:

Assignment:

• Subjective: What details did the patient provide regarding her personal and medical history?
• Objective: What observations did you make during the physical assessment?
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
• Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
• Reflection notes: What would you do differently in a similar patient evaluation?

Note: Your Focused Note Assignment must be signed by Day 7 of Week 9.

 

By Day 7

Submit your Episodic/Focused Note Assignment.
(Note: You will submit two files, your Focused Note Assignment, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 9.)

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

1. To submit your completed assignment, save your Assignment as WK9Assgn2_LastName_Firstinitial
2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for review.

Rubric

PRAC_6531_Week9_Assignment2_Rubric

PRAC_6531_Week9_Assignment2_Rubric

Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeOrganization of Write-up	10 to >6.0 ptsExcellentAll information organized in logical sequence; follows acceptable format and utilizes expected headings. 6 to >3.0 ptsGoodInformation generally organized in logical sequence; follows acceptable format and utilizes expected headings. 3 to >0.0 ptsFairErrors in format; information intermittently organized. Headings are used some of the time. 0 ptsPoorErrors in format; information disorganized. Headings are not used appropriately.	10 pts
This criterion is linked to a Learning OutcomeThoroughness of History	20 to >15.0 ptsExcellentThoroughly documents all pertinent history components for type of note; includes critical as well as supportive information. 15 to >11.0 ptsGoodDocuments most pertinent examination components. 11 to >7.0 ptsFairDocuments some pertinent examination components. 7 to >0 ptsPoorPhysical examination cursory; misses several pertinent components.	20 pts
This criterion is linked to a Learning OutcomeHistory of Present Illness	10 to >6.0 ptsExcellentThoroughly documents all 8 aspects of HPI and pertinent other data relevant to chief complaint. Includes critical as well as supportive information. 6 to >4.0 ptsGoodDocuments at least 6 aspects of the HPI and pertinent other data relevant to chief complaint. Includes critical information. 4 to >2.0 ptsFairDocuments at least 4 aspects of HPI and some data pertinent to chief complaint. Lacks some critical information or rambling in history. 2 to >0 ptsPoorMissing many aspects of HPI and pertinent data. Critical information missing.	10 pts
This criterion is linked to a Learning OutcomeThoroughness of Physical Exam	10 to >7.0 ptsExcellentThoroughly documents all pertinent examination components for type of note. 7 to >4.0 ptsGoodDocuments most pertinent examination components. 4 to >2.0 ptsFairDocuments some pertinent examination components. 2 to >0 ptsPoorPhysical examination cursory; misses several pertinent components.	10 pts
This criterion is linked to a Learning OutcomeDiagnostic Reasoning	10 to >7.0 ptsExcellentAssessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when ordering diagnostic tests. 7 to >4.0 ptsGoodAssessment consistent with prior documentation. Clear justification for diagnosis. Notes most secondary problems. 4 to >2.0 ptsFairAssessment mostly consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests. 2 to >0 ptsPoorAssessment not consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests.	10 pts
This criterion is linked to a Learning OutcomeTreatment Plan/Patient Education	20 to >15.0 ptsExcellentTreatment plan addresses all issues raised by diagnoses, excellent insight into patient’s needs. Medications prescribed are appropriate and full prescription is included. Evidence based decisions. Cost effective treatment. 15 to >10.0 ptsGoodTreatment plan addresses most issues raised by diagnoses. Medications prescribed are appropriate but include 1 or 2 error in writing prescription. 10 to >5.0 ptsFairTreatment plan fails to address most issues raised by diagnoses. Medications are inappropriate or include 3 or more errors in writing prescription. 5 to >0 ptsPoorMinimal treatment plan addressed. Medications are inappropriate or poorly written prescription.	20 pts
This criterion is linked to a Learning OutcomePatient Education / Follow Up / Reflection	10 to >8.0 ptsExcellentPatient education addresses all issues raised by diagnoses, excellent insight into patient’s needs. Follow up plan in appropriate and reflects acuity of illness. Reflection is thoughtful and in depth. 8 to >5.0 ptsGoodPatient education addresses most issues raised by diagnoses. Follow up plan is appropriate but lacks specifics Reflection is thoughtful and in depth. 5 to >3.0 ptsFairPatient education fails to address most issues raised by diagnoses. Follow up plan is lacking specifics or is inappropriate for patient acuity. Reflection is brief, vague. and does not discuss anything that would have been done in addition to or differently. 3 to >0 ptsPoorMinimal patient education addressed. Follow up plan is inappropriate Reflection is absent.	10 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting English writing standards: Correct grammar, mechanics, and proper punctuation. Professional language utilized	5 ptsExcellentUses correct grammar, spelling, and punctuation with no errors. Professional language utilized. 4 ptsGoodContains a few (1-2) grammar, spelling, and punctuation errors. Contains a few errors (1 or 2) in professional language use. 2 ptsFairContains several (3-4) grammar, spelling, and punctuation errors. Contains several errors (3 -4) in professional language use. 0 ptsPoorContains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. Contains many errors in professional language use.	5 pts
This criterion is linked to a Learning OutcomeScholarly References and Clinical Practice Guidelines. The assignment includes a minimum of 3 scholarly references that are not older than 5 years. Clinical practice guidelines are included if applicable.	5 ptsExcellentContains parenthetical/in-text citations and at least 3 evidenced based references less than 5 years old are listed. Clinical practice guidelines are cited if applicable. 4 ptsGoodContains parenthetical/in-text citations and at least 2 evidenced based references less than 5 years old are listed. Clinical practice guidelines are cited if applicable. 2 ptsFairContains parenthetical/in-text citations and at least 1 evidenced based reference less than 5 years old is listed. Clinical practice guidelines are not cited if applicable. 0 ptsPoorContains no parenthetical/in-text citations and 0 evidenced based references listed. Clinical practice guidelines are not cited if applicable.	5 pts

Total Points: 100

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