Conditions of the Musculoskeletal and Neurovascular Systems Results-Documentation
Conditions of the Musculoskeletal and Neurovascular Systems Results-Documentation
Conditions of the Musculoskeletal and Neurovascular Systems Results-Documentation
Conditions of the Musculoskeletal and Neurovascular Systems Results | Completed Primary Care Nursing - FNP III - Advanced Diagnostics Content - September 2020, NUR 532 Return to Ass ignment (/assignments/390944/) Your Results Turn In (/assignment_attempts/8212268/choose Lab Pass (/assignment_attempts/8212268/lab_pass.p Overview Transcrip t Subjective Data Collection Documentation / Electronic Health Record Flowsheets My Provider Notes Objective Data Collection Education & Empathy Documentation My Provider Notes Student Documentation Model Documentation Differential Selection Test Selection Test Linkin g Test Review Final Diagnosis Self-Reflection Subjective Pt is an 11 yo white female, alert and oriented, and accompanied by her father Ned. Pt is answering questions and can describe her current illness. Pt has c/o knee pain that started 3 weeks ago as a dull ache and pt fell off her horse 2 days ago that aggre vated her knee pain. Pt has a history of diabetes type 1 which is managed with insulin glargine and diagnosed 6 months ago. Prior hospitalization includes DKA 6 months ago. Pt sees an endocrinologist to manage her DM. Pt uses insuline glargine in the morni ngs. Pt rides horses 3/week and does not like to wear a helmet. CC: “I fell off of Sparkle two days ago, and my knee has been hu since.” Chelsea presents to clinic ambulatory without the use of assistiv devices. Chelsea states that she fell off of Sparkle, her adult hor from a height of two feet while the horse was stationary. This occurred two days ago, and she has been having intermittent pa inferior to her kneecap since the fall. Ned, her father, present for exam, provides context and further clarification. He states the pa actually started “a little while before the fall”. She states, “I was mounting my horse and slid down. I fell and a landed on my knee.” She landed on the grass, and her skin is int She denies hitting her head or losing consciousness. She is able walk without a limp and denies severe pain. She reports addition “Two days ago, I fell, didn’t scrape my knee or anything, but it did swell up some, but it’s gone now. I noticed the pain more when moving around. I’m still walking fine but it really hurts.” Chelsea’s began before the fall. She reports “Two weeks ago, I noticed tha while jumping/running/riding my left knee would s tart to hurt. I did really think about it because I’m getting taller. When I stopped to it would go away.” Her father reports that she is not taking acetaminophen, because the pain is relieved when she rests, an she is not using the ice packs that he recom mended because sh doesn’t like to touch her knee. She reports her pain as “really, re bad” with activity, but simply “uncomfortable” at other times. She didn’t report it because she was afraid her horse would get taken away. Ned affirms she uses helmets regularly but declines to use knee pads due to peer pressure regarding the way they make he look. Of particular importance, the patient was discharged from the ho 60 days ago with a diagnosis of DKA secondary to newly diagno Type 1 diabetes mellitus. Then , she had completed her initial po discharge visit with endocrinology. She was prescribed insulin sli scale and she is following the insulin regimen and glucose monit and her diabetic diet as per her endocrinologist recommendation Allergies •No known dru g, latex, environmental, or pet allergies. Home Medications Support
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