Helen McDonald 10/08/09 Musculoskeletal System A.B. DOB 07/10/76 CC: lo!e" #ack $a%n &o" ' ( y"s.

) HO*+: *t %s a ,, yea" old &emale !-o $"esents to t-e cl%n%c !%t- c/o lo!e" #ack $a%n &o" t-e $ast ' ( yea"s. .-e $t states -e" #ack $a%n #e/an !-en -e" a$$"o0%mately ,0 l# son 1um$ed on -e" #ack. He" -us#and t-en ca""%ed -e" %nto t-e%" ca" and d"o2e -e" to s-e -e" $"%ma"y ca"e $-ys%c%an. .-e $at%ent t-en -ad an M3+4 !-%c- "e2ealed a -e"n%ated 5' d%sk. .-e $t states -e" $a%n %s %nte"m%ttent and o"%/%nates %n -e" lo!e" #ack "ad%at%n/ do!n -e" le&t le/. .-e $t also states t-e m%ddle o& -e" le&t t-%/- %nte"m%ttently /ets num#. .-e $at%ent states -e" $a%n can #e as #ad as a 7 out o& 10 on t-e $a%n scale. *t states t-at somet%mes l%&t%n/ -e" k%ds and ot-e" -ea2y t-%n/s suc- as /"oce"%es make -e" $a%n !o"se. *t states %ce4 and -eat make -e" $a%n #ette". *t states s-e takes al%2e to make -e" $a%n #ette". *t "e$o"ts %nte"m%ttent dec"eased a#%l%ty to -y$e"e0tend and &le0 -e" #ack !%t-out $a%n. *t den%es any "esent !e%/-t c-an/es. .-e $t den%es any d%&&%culty c-e!%n/. *MH: *t states all t-e l%/aments %n -e" "%/-t ankle !e"e to"n a&te" a &all do!n 10 sta"es !-en s-e !as 17 yea"s old %n -e" -%/- sc-ool. *t states s-e !o"e a cast on t-at ankle &o" , mont-s. *t states s-e -as no "es%dual $a%n #ut %t does /et some!-at so"e and st%&& %n t-e !%nte". *t states s-e does tend to t!%st) -e" t%/-t ankle mo"e. *t !%t- c/o mo"n%n/ st%&&ness to -e" -ands. *t states s-e -as dec"eased a#%l%ty to &le0 and e0tend -e" &%n/e"s %n t-e mo"n%n/. *t states a !a"m s-o!e" makes -e" -and st%&&ness #ette". *t states cold !eat-e" makes -e" st%&&ness !o"se. *t den%es any ot-e" %n1u"y o" $a%n to -e" musculoskeletal system. *t states -e" last tetanus %mmun%6at%on !as Ma"c- o& '007. *t states -e" c-%ld-ood %mmun%6at%ons a"e u$ to date. *t den%es -a2%n/ d%a#etes mell%tus4 s%ckle cell anem%a4 system%c lu$us e"yt-ematosus o" osteo$o"os%s. 7H: *ts &am%ly -%sto"y %s noncont"%#uto"y to -e" #ack $a%n. *t den%es &am%ly -%sto"y o& "-eumato%d a"t-"%t%s4 /out4 o" osteo$o"os%s. 5%&estyle and Healt- *"act%ces: *t states s-e !alks on a t"eadm%ll &o" one8-ou" e2e"yday. *t states s-e takes calc%um !%t- 2%tam%n D e2e"yday and *39 O.C Al%2e &o" #ack $a%n. *t states s-e %s not tak%n/ any $"esc"%$t%on med%cat%ons. *t den%es to#acco4 alco-ol o" ca&&e%ne use. *. states s-e -as ade:uate nut"%t%onal %ntake o& $"ote%n and m%lk8conta%n%n/ $"oducts. *t states s-e s$ends m%n%mal t%me %n t-e sunl%/-t. *t states -e" da%ly act%2%t%es %nclude; tak%n/ ca"e o& -e" &am%ly4 cook%n/4 clean%n/4 /"oce"y s-o$$%n/. *t states s-e %s em$loyed $e" d%em as a "es$%te nu"se. *t states s-e !o"ks <1=-"s/!k. *t states s-e -as /ood $ostu"e s%tt%n/ and stand%n/. *t states s-e %s a#le to $e"&o"m AD5>s %nde$endently and %s a#le to am#ulate !%t-out ass%st%2e de2%ces. *t states -e" musculoskeletal $"o#lems

%nte"&e"e !%t- -e" not #e%n/ a#le to ca""y -e" k%ds as o&ten as s-e !ould l%ke. *t states no"mal soc%al %nte"act%on and se0ual act%2%ty %s not %nte"&e"ed. *t states -e" musculoskeletal $"o#lems -a2e not added st"ess to -e" l%&e. *-ys%cal ?0am%nat%on @a%t: Cl%ent %s = &eet4 A %nc-es4 !e%/-s 1,0 l#s. @a%t smoot-4 !%t- e:ual st"%de and /ood #ase o& su$$o"t. ?2enly d%st"%#uted !e%/-t noted. Cl%ent %s a#le to stand on -eels and toes. *t>s $ostu"e %s e"ect4 mo2ements a"e coo"d%nated and "-yt-m%c4 a"ms s!%n/ %n o$$os%t%on4 and st"%de len/t- %s a$$"o$"%ate. .M@: 1a! a$$ea"s symmet"%cal !%t- no o#2%ous lum$s o" s!ell%n/ noted *al$at%ons "e2eals smoot- o$en%n/ and clos%n/ o& t-e 1a!. . 7ull 3OM o& .MB !%t- no $a%n4 tende"ness4 cl%ck%n/4 o" c"e$%tus noted. Ba! mo2es late"ally 18'cm. 9o sna$$%n/ o" cl%ck%n/ noted. Mout- o$ens and closes smoot-ly !%t- out d%&&%culty. .MB muscle st"en/t- %s a = on t-e st"en/t- ta#le. Ste"nocla2%cula" Bo%nt: .-e"e %s no #ony o2e"/"o!t- s!ell%n/ o" "edness noted. Ste"nocla2%cula" 1o%nts a"e symmet"%cal. C$on $al$at%on t-e"e %s no tende"ness noted. Ce"2%cal4 .-o"ac%c4 and 5um#a" S$%ne: S-oulde"s4 %l%ac c"ests and #uttocks c"eases a"e symmet"%cal and o& t-e same -e%/-t. Ce"2%cal and lum#a" s$%nes a$$ea" conca2e. .-o"ac%c s$%ne a$$ea"s con2e0. .-e s$%ne a$$ea"s st"a%/-t !-en o#se"2ed &"om #e-%nd. S$%nous $"ocesses a"e non8tende"4 !ell8de2elo$ed4 &%"m and smoot-. .-e $a"a2e"te#"al muscles a"e non8tende" !%t- no muscle s$asms noted. 7le0%on and e0tens%on o& t-e ce"2%cal s$%ne %s A= de/"ees %n e%t-e" d%"ect%on. 9o $a%n noted. .-e $at%ent %s a#le to #end A0 de/"ees to t-e le&t and A0 de/"ees to t-e "%/-t du"%n/ late"al #end%n/ o& t-e neck. Act%2e "otat%on o& t-e neck "e2eals t-e $at%ent %s a#le to tu"n t-e -ead to t-e "%/-t and le&t a$$"o0%mately 70 de/"ees %n e%t-e" d%"ect%on !%t- no $a%n noted. 90 de/"ees &le0%on %s noted to t-e t-o"ac%c and lum#a" s$%ne !-en $at%ent touc-es -e" toes. .-e s$%ne "ema%ns st"a%/-t. 5ate"al #end%n/ o& t-e t-o"ac%c and lum#a" s$%nes "e2eal ,= de/"ees mo2ement %n e%t-e" d%"ect%on. *t %s a#le to -y$e"e0tend a#out ,0 de/"ees "otat%on o& t-e t-o"ac%c and lum#a" s$%ne %n e%t-e" d%"ect%on. .-e $at%ent %s a#le to "a%se #%late"al le/s 90 de/"ees one at a t%me du"%n/ 5ase/ue>s test !%t-out $"oduc%n/ $a%n. S-oulde"s and A"ms: s-oulde"s and a"ms a$$ea" symmet"%cal and $%nk !%t- no S!ell%n/4 de&o"m%ty o" masses noted. Cla2%cles and sca$ulae a"e e2en and symmet"%c. C$on $al$at%on no tende"ness4 s!ell%n/ o" -eat %s noted. *at%ent %s a#le to &le0 t-e a"ms &o"!a"d 180 de/"ees. *t %s a#le to -y$e"e0tend t-e a"ms =0 de/"ees. *t %s a#le to adduct t-e a"ms =0 de/"ees and a#duct t-e a"ms 180 de/"ees. *t %s a#le to e0te"nally and %nte"nally "otate t-e s-oulde"s 90 de/"ees. *t %s a#le to &le04 e0tend4 adduct4 a#duct4 "otate and s-"u/ s-oulde"s a/a%nst "es%stance. 9o $a%n %s noted du"%n/ any o& t-e s-oulde" and a"m mo2ements. Muscle st"en/t- %s noted to #e a = on t-e st"en/t- ta#le t-"ou/- all 3OM e:ually to BC?. ?l#o!s: ?l#o!s a$$ea" symmet"%c !%t-out de&o"m%ty4 "edness o" s!ell%n/ noted. C$on $al$at%on t-e"e %s no tende"ness4 o" nodules noted. 160 de/"ees o& &le0%on4 180 de/"ees o& e0tens%on4 90 de/"ees o& $"onat%on4 90 de/"ees o& su$%nat%on a"e noted to #%late"al el#o!. .-e cl%ent -as &ull "an/e o& mot%on noted to #%late"al !%t- a "ate

o& = on t-e muscle st"en/t- ta#le e:ual to #%late"al el#o!. D"%sts: t-e !"%sts a"e noted to #e symmet"%c !%t-out "edness o" s!ell%n/. .-ey a"e non tende" !%t- no nodules noted. no tende"ness noted %n t-e anatom%c snu&&#o! to #%late"al !"%sts. 90 de/"ees &le0%on4 70 de/"ees -y$e"e0tens%on4 == de/"ees ulna" de2%at%on and '0 de/"ees "ad%al de2%at%on %s noted. &ull 3OM %s noted a/a%nst "es%stance !%t- a "ate o& = on t-e muscle st"en/t- sco"e and %s e:ual to #%late"al !"%sts.. *-alen>s test and .%nel>s s%/n "e2eals no t%n/l%n/4 num#ness4 o" $a%n. Hands and 7%n/e"s: -ands and &%n/e"s a"e symmet"%c4 non8tende" and !%t-out nodules. 7%n/e"s a"e noted to l%e %n a &"ont l%ne. 9o s!ell%n/ o" de&o"m%t%es a"e noted. $t %s a#le to &le0 and e0tend &%n/e"s !%t-out $a%n and !%t- &ull 3OM. '0 de/"ees o& a#duct%on4 90 de/"ees o& &le0%on and ,0 de/"ees o& -y$e"e0tens%on a"e noted to t-e &%n/e"s. .-e cl%ent -as &ull 3OM a/a%nst "es%stance !%t- a "ate o& = on t-e muscle st"en/t- ta#le and %s e:ual on #%late"al -ands and &%n/e"s. H%$s: t-e #uttocks a"e o& e:ual s%6e. .-e %l%ac c"ests a"e symmet"%c %n -e%/-t. H%$s a"e sta#le4 non8tende" and !%t-out c"e$%tus. 90de/"ee -%$ &le0%on %s noted !%t- t-e knees st"a%/-t. =0 de/"ees & a#duct%on and ,0 de/"ees o& adduct%on %s noted mo2%n/ t-e le/ e0tended le/ to and &"om t-e m%dl%ne. A0 de/"ess o& #%late"al %nte"nal -%$ "otat%on %s noted and A= de/"ees o" e0te"nal -%$ "otat%on noted. 1= de/"ees o& #%late"al -%$ -y$e"e0tens%on %s noted to #%late"al -%$s. 7ull 3OM a/a%nst "es%stance %s noted to #%late"al -%$s !%t- a "ate o& = on t-e muscle ta#le e:ual to #%late"al -%$s. Enees: B%late"al knees a$$ea" symmet"%c and e:ual %n s%6e. Hollo!s $"esent on #ot- s%des o& t-e $atella. 9o s!ell%n/ o" de&o"m%t%es noted. B%late"al lo!e" le/s a"e %n al%/nment !%t- #%late"al u$$e" -%$s. C$on $al$at%on t-e 1o%nts a"e non8tende" and cool to t-e touc-. Muscles a"e &%"m and no nodules a"e $al$ated. 9o #ul/es o& &lu%d a$$ea" on med%al s%de o& knee !-en $e"&o"m%n/ t-e #ul/e test to #%late"al knees. 9o mo2ements o& t-e $atella a"e noted to #%late"al knees du"%n/ t-e #allottement test. *al$at%on o& t-e t%#%o&emo"al s$ace "e2ealed no $a%n o" c"e$%tus. 1,0 de/"ees o& &le0%on %s noted to #%late"al knees. 1= de/"ees o& -y$e"e0tens%on %s noted to #%late"al knees. Cl%ent -as &ull 3OM a/a%nst "es%stance %s noted !%t- a scale o& = on t-e muscle st"en/t- ta#le and e:ual on #%late"al knees. Ankles and 7eet: toes a"e $o%nt%n/ &o"!a"d and l%e%n/ &lat. .-e toes and &eet a"e %n al%/nment !%t- t-e lo!e" le/s. Smoot-4 "ounded med%al malleola" $"om%nences a"e noted !%t- $"om%nent -eels and metata"so$-alan/eal 1o%nts. .-e sk%n %s smoot- and &"ee o& co"ns and calluses. .-e ankles and &eet a"e non8tende" !%t- no -eat s!ell%n/ o" nodules noted. '0 de/"ees o& do"s%&le0%on o& #%late"al ankles and &oot a"e noted. A= de/"ees o& $lanta" &le0%on o& #%late"al ankle and &oot a"e noted. '0 de/"ees o& e2e"s%on and ,0 de/"ees o& %n2e"s%on a"e noted to #%late"al &eet.. A0 de/"ees o& &le0%on and A0 de/"ees o& e0tent%on a"e noted to #%late"al toes. Cl%ent -as &ull 3OM a/a%nst "es%stance o& #%late"al ankles and &eet !%t- a "ate o& = on t-e muscle ta#le. 9D; 3ead%ness &o" en-anced act%2%ty and e0e"c%se $atte"ns "/t $-ys%cal a#%l%ty A?B $-ys%cal e0am%nat%on o& t-e musculoskeletal assessment. 3%sk &o" %ne&&ect%2e se0ual%ty $atte"n "/t lo!e" #ack $a%n A?B $t Fs com$la%nt o& lo!e"

#ack $a%n. C-"on%c $a%n "/t #one $"o#lems A?B $t>s c/o lo!e" #ack $a%n.