Assessing Musculoskeletal Pain
Student’s Name:
Institutional Affiliation:
Musculoskeletal pain is a common phenomenon of which nearly everyone has to experience at a given point in their lives. There are different causes of musculoskeletal pain, but the most common causes are trauma, strain from daily activities and diseases (Baker et al., 2017). The regions that may elicit pain are the muscles, joints, bones, and periarticular tissues but the impact depends on the severity and nature of injury. In assessing a patient with Musculoskeletal pain both subjective and objective approaches are used for proper diagnosis and treatment. The caregiver has to assess the current symptoms of the patient, how it evolved, surrounding factors, and the impact of the problem on the individual’s health and quality of life. This paper aims to conduct a review of an ankle pain case study of a soccer player to assess her condition and recommend the right treatment.
Episodic/Focused SOAP Note
Focused SOAP Note for a patient with ankle pain.
Patient Information
The patient is a 46-year-old white female
S.
Chief complaint: Ankle pain
The patient visited complaining of pain in both legs, mainly within the ankle areas. Her most significant concern was with her right leg. She explains that she felt a pop in the ankle region during a game of soccer. From a general view when she entered, she can bear her weight but she is limping uncomfortably. The patient does also look stressed and fatigued.
HPI: Using LOCATES.
Current Medications: The patient was subjected to over the counter NSAIDs, with a dosage of Ibuprofen 200mg, one pill for every six hours for the past two days. The reason for taking the pills was to relieve the pain felt in the ankle. The patient had also tied the ankle region with a bandage for support. The patient did also take alcohol to sedate the pain.
Allergies: The patient has no history of any allergies, either for food or drugs
Soc Hx: The patient is a soccer player, married for 20 years, has negative use of tobacco or any smoking drugs, consumes a lot of coffee, and moderate alcohol.
ROS:
General- The patient seems to be in pain, stressed, and fatigued.
Cardiovascular–Negative of complicated heart conditions and diseases
Gastrointestinal–Positive for vomiting but it is after excessive alcohol intake; negative for stomach upsets and abdominal pain.
Constitutional – The patient admits to weight increase recently and frequent fatigue.
Eyes – no changes in vision; wears glasses only when reading.
ENT – Hearing is definite: does not wear hearing aids.
Skin/Breast – no allergies or rashes; Warm and red on the right ankle
Pulmonary – Easy to breathe in and out; no shortness of breath; no cough
Endocrine – Appetite still intact
Genito Urinary – No pain or irregularity in urination frequency. Some urge was due to alcohol intake; Negative of infections.
Musculo Skeletal – Changes in strength, pain in both legs, swelling, strain during walking.
Neurologic – Memory is unaffected
Psychology – Appears stressed, uncomfortable, and restless.
Heme/Lymph – Negative of easy bruising
O.
Head to toe examination.
Vitals: Temp: 98°F BP: 125/86mmHg BMI: 28
General: The patient looks calm though stressed and fatigued, weight/ height are proportionate.
Skin: Warm, dry, well-perfused; No visible rashes, the right leg ankle region is swollen, with redness.
Extremities: positive lower extremity pain or edem
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