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Template Case Study Chosen: Demographics: Age/Gender SUBJECTIVE CC: HPI: (

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Template
Case Study Chosen:
Demographics: Age/Gender
SUBJECTIVE
CC:
HPI: (

Template
Case Study Chosen:
Demographics: Age/Gender
SUBJECTIVE
CC:
HPI: (As listed from Case Study Information)
Subjective: (What questions will you ask? Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent).

OBJECTIVE
General:
VS BP, HR, RR, Weight, Height, BMI
Physical Exam Elements: (Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent.)
POC Testing (any Point of Care (POC) testing specifically performed in the office): What tests (if any) did you perform during the visit (urine dip, rapid strep, urine pregnancy test, Glucose finger-stick, etc.)? Leave blank if none.

ASSESSMENT
Working Diagnosis: (Must include ICD 10)
Differential Diagnosis:

PLAN
Diagnostic studies: If any, will be ordered (Labs, X-ray, CT, etc.). Only include if you will be ordering for your patient. Remember the importance of appropriate resource utilization. Remember you are managing this patient in the CLINIC setting, NOT THE HOSPITAL.
Treatment: Must include full Sig/Order for all prescriptions and OTC meds (Name of medication, dosage, frequency, duration, number of tabs, number of refills). CANNOT only list drug class. Should follow evidence-based guidelines.
Referrals: If Applicable
Education:
Health maintenance:
RTC:

Week 5 Discussion Board Prompts – Musculoskeletal
Susan is a 30-year-old registered nurse who works in transitional care. She presents to employee health stating, “My back is killing me. I was helping to transfer a patient and he moved. I thought he was going to fall, so I twisted around to grab onto him and wrenched my back. The pain is terrible, and I can barely walk.” Susan is a healthy young adult, married with a 5-year old daughter. She has no significant family history. Susan has a past medical history of fractured coccyx as a teenager when she fell during cheerleading practice; no sequelae. She has smoked one-half pack of cigarettes a day since age 15 but is trying to quit. Current medicines include medroxyprogesterone acetate (Depo Provera) injection for birth control every 13 weeks. She is supposed to take calcium, but states that she “always forgets, and it constipates me anyway.” Susan denies any change in bowel/bladder habits.

Table 1. Common Musculoskeletal Diagnoses. In addition to your SOAP note, you must also complete the following table.
Diagnosis Signs/Symptoms Gold Standard Diagnostics Gold Standard Treatment
Low back pain/lumbago
Cauda Equina Syndrome
Plantar Fasciitis
Degenerative Joint Disease (Osteoarthritis)
Ankylosing Spondylitis
Meniscus Tear
Hip Fracture
Pelvic Fracture
Navicular Fracture
Colles Fracture
Ankle Sprain

**Clinical Pearl**
Type of Scan Indication Special Considerations
X-ray
Bone fractures/damage, OA, metal, dense objects
MRI Gold standard for injuries to cartilage, meniscus, tendons and ligaments
No metal, pacemakers, aneurysm clips
CT
Views structures like masses, trauma, fractures, bleeding. Forms 3-D picture
More cost effective than MRI

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