Posted: October 22nd, 2024

Episodic/Focused Note: Musculoskeletal Focused Note

Episodic/Focused Note: Musculoskeletal Focused Note Assignment Example

Patient Information:

Initials: J.S.

Age: 52

Sex: Female

Race: Caucasian

S. (Subjective)

CC: “My right knee has been hurting for weeks.”

HPI: A 52-year-old Caucasian female presents with a chief complaint of right knee pain for the past 6 weeks. The pain is described as a dull ache that worsens with activity, particularly climbing stairs and walking long distances. She reports no history of trauma to the knee. The pain is located in the medial aspect of the knee and is rated as a 5/10 on the pain scale. She denies any locking, clicking, or swelling. She reports taking over-the-counter ibuprofen for pain relief with some temporary improvement. She denies any history of knee injuries or surgeries.

Current Medications: Ibuprofen 200mg every 6 hours as needed for pain.

Allergies: None reported.

PMHx: Hypertension, well-controlled with medication. Appendectomy at age 18.

Soc Hx: Works as a cashier at a grocery store. Enjoys gardening and walking. Lives with her husband and two adult children. No tobacco or alcohol use.

Fam Hx: Mother has osteoarthritis.

ROS:

General: No fever, chills, weight loss, or fatigue.

HEENT: No headache, dizziness, or visual changes.

Cardiovascular: No chest pain, palpitations, or edema.

Respiratory: No cough, shortness of breath, or wheezing.

Gastrointestinal: No nausea, vomiting, or diarrhea.

Genitourinary: No urinary frequency or burning.

Neurological: No numbness or tingling.

Musculoskeletal: Pain in right knee.

Hematologic: No bleeding or bruising.

Lymphatic: No swollen lymph nodes.

. Psychiatric: No depression or anxiety.

Endocrine: No sweating or heat intolerance.

O. (Objective)

General: Alert and oriented x3. In no apparent distress.

HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive to light.

Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops.

Respiratory: Clear to auscultation bilaterally.

Gastrointestinal: Soft, non-tender abdomen.

Musculoskeletal: Right knee: Tenderness to palpation over medial joint line. Full range of motion with pain. No swelling.

A. (Assessment)

Primary Diagnosis: Likely osteoarthritis of the right knee.

Differential Diagnoses:

Secondarily: Meniscus tear.

Third: Referred pain from the hip.

P. (Plan)

Diagnostic Studies: X-ray of the right knee.

Treatment:

Pharmacologic: Continue ibuprofen as needed.

Non-pharmacologic: Ice and compression. Physical therapy referral for strengthening exercises.

Follow-up: Follow-up in 2 weeks.

Reflection:

This case highlights the importance of a thorough history and physical exam in diagnosing musculoskeletal conditions. I was able to narrow down the differential diagnoses based on the patient’s history and physical exam findings. I will continue to refine my skills in physical exam techniques to improve my diagnostic accuracy.

References

Keywords: Musculoskeletal, osteoarthritis, knee pain, physical exam, diagnosis, treatment plan, patient education.

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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
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 pts
Excellent
All information organized in logical sequence; follows acceptable format and utilizes expected headings. 6 to >3.0 pts
Good
Information generally organized in logical sequence; follows acceptable format and utilizes expected headings. 3 to >0.0 pts
Fair
Errors in format; information intermittently organized. Headings are used some of the time. 0 pts
Poor
Errors 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 pts
Excellent
Thoroughly documents all pertinent history components for type of note; includes critical as well as supportive information. 15 to >11.0 pts
Good
Documents most pertinent examination components. 11 to >7.0 pts
Fair
Documents some pertinent examination components. 7 to >0 pts
Poor
Physical examination cursory; misses several pertinent components.
20 pts
This criterion is linked to a Learning OutcomeHistory of Present Illness 10 to >6.0 pts
Excellent
Thoroughly 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 pts
Good
Documents at least 6 aspects of the HPI and pertinent other data relevant to chief complaint. Includes critical information. 4 to >2.0 pts
Fair
Documents at least 4 aspects of HPI and some data pertinent to chief complaint. Lacks some critical information or rambling in history. 2 to >0 pts
Poor
Missing 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 pts
Excellent
Thoroughly documents all pertinent examination components for type of note. 7 to >4.0 pts
Good
Documents most pertinent examination components. 4 to >2.0 pts
Fair
Documents some pertinent examination components. 2 to >0 pts
Poor
Physical examination cursory; misses several pertinent components.
10 pts
This criterion is linked to a Learning OutcomeDiagnostic Reasoning 10 to >7.0 pts
Excellent
Assessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when ordering diagnostic tests. 7 to >4.0 pts
Good
Assessment consistent with prior documentation. Clear justification for diagnosis. Notes most secondary problems. 4 to >2.0 pts
Fair
Assessment mostly consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests. 2 to >0 pts
Poor
Assessment 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 pts
Excellent
Treatment 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 pts
Good
Treatment plan addresses most issues raised by diagnoses. Medications prescribed are appropriate but include 1 or 2 error in writing prescription. 10 to >5.0 pts
Fair
Treatment plan fails to address most issues raised by diagnoses. Medications are inappropriate or include 3 or more errors in writing prescription. 5 to >0 pts
Poor
Minimal 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 pts
Excellent
Patient 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 pts
Good
Patient 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 pts
Fair
Patient 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 pts
Poor
Minimal 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 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors. Professional language utilized. 4 pts
Good
Contains a few (1-2) grammar, spelling, and punctuation errors. Contains a few errors (1 or 2) in professional language use. 2 pts
Fair
Contains several (3-4) grammar, spelling, and punctuation errors. Contains several errors (3 -4) in professional language use. 0 pts
Poor
Contains 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 pts
Excellent
Contains 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 pts
Good
Contains 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 pts
Fair
Contains 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 pts
Poor
Contains 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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Tags: Episodic/Focused Note