Instructions:
Patient Case- you should embellish and add additional details to the patient case as needed to reflect full documentation of a musculoskeletal problem, but please use the following basic information to document about your patient:
Background info (Subjective Data)
Mrs. Bluejay is an 80-year-old Native American female who recently fell on her right hip, requiring hospitalization. She has been in the skilled nursing facility for 10 days for rehabilitation with physical therapy.
Current medications include alendronate sodium (Fosamax) for osteoarthritis. Supplements are a multivitamin, vitamin D, calcium, and magnesium.
She has no known food, drug, or environmental allergies.
Past medical history: arthritis
HPI: She is currently in pain. She reports pain: 4/10 in her right hip from the fall. Ask her more OLDCARTS about her current symptoms and make up what her answers may be.
Physical Examination (Objective Data)
Vital Signs: Oral Temp 36.6 C, HR 82 BPM, RR 18, and BP 122/64.
Inspection: mild kyphosis, right hip limited range of motion. Document rest of inspection as a normal or expected finding.
Palpation: Tenderness of right hip. Muscle strength 3/5 of right hip. Document other extremities and palpation as a normal or expected finding.