Walden University, Advanced Health Assessment6512, Week 8.
Please use the following resources for all citations/references:
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 6, “Vital Signs and Pain Assessment” (Previously read in Week 6)
Chapter 22, “Musculoskeletal System”
This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 22, “Lower Extremity Limb Pain”Download Chapter 22, “Lower Extremity Limb Pain”
This chapter outlines how to take a focused history and perform a physical exam to determine the cause of limb pain. It includes a discussion of the most common tests used to assess musculoskeletal disorders.
Chapter 24, “Low Back Pain (Acute)” Download Chapter 24, “Low Back Pain (Acute)” The focus of this chapter is the identification of the causes of lower back pain. It includes suggested physical exams and potential diagnoses.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
Chapter 2, "The Comprehensive History and Physical Exam" ("Muscle Strength Grading") (Previously read in Weeks 1, 2, 3, 4, and 5)
Chapter 3, "SOAP Notes"
This section explains the procedural knowledge needed to perform musculoskeletal procedures.
Document: Episodic/Focused SOAP Note Exemplar (Word document)Download
Episodic/Focused SOAP Note Exemplar (Word document)
Document: Episodic/Focused SOAP Note Template (Word document)
Evaluate abnormal musculoskeletal findings
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the musculoskeletal system
Evaluate musculoskeletal X-ray imaging
Your Discussion post should be in the "Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format". Refer to Chapter 2 of the Sullivan text and the "Episodic/Focused SOAP Template in the Week 5" Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case. "Make up" the necessary information to complete the soap note.
Review the following case studies:
Case 1: Back Pain
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins of using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
With regard to the case study you were assigned:
*Review this week’s Learning Resources and consider the insights they provide about the case study.
*Consider what history would be necessary to collect from the patient in the case study you were assigned.
*Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
*Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
*Note: Before you submit your initial post, replace the subject line ("Discussion – Week 8") with "Review of Case Study ___." Fill in the blank with the number of the case study you were assigned.
By Day 3 of Week 8:
*Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources.
*Provide evidence from the literature to support diagnostic tests that would be appropriate for each case.
*List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
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