MUSCULOSKELETAL AND NEUROVASCULAR SYSTEM SHADOW HEALTH DOCUMENTATION
10/16/22, 6:01 PM Chelsea Warren Musculoskeletal and Neurovascular Systems shadow health Documentation
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Chelsea Warren Musculoskeletal And Neurovascular Systems Shadow Health
Documentation
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Chelsea Warren Musculoskeletal and Neurovascular Systems
shadow health Documentation
Documentation / Electronic Health Record
Flowsheets My Provider Notes
My Provider Notes
Student Documentation Model Documentation
Subjective
CC ” I feel off of sparkle two days ago, and my knee has been
hurting since” Chelsea is an 11-y/o Caucasian female who presents
CC: “I fell off of Sparkle two days ago, and my knee has been
hurting since.” Chelsea presents to clinic ambulatory without the
use of assistive devices. Chelsea states that she fell off of Sparkle,
Student Documentation to the clinic after falling off her adult horse from a height of two Model Documentation
feet two days ago. She is experiencing intermittent pain below to her
knee cap since the fall. The patent is present with the fatehr Ned
who stated that the pain started a little before the a fall. Patient
stated her pain is getting worse as she is unable to take of her
panst and riding boots. Laying and sitting down provides her with
relieve from it. Also patient was hospitalized sixty days ago with a
diagnosis of DKA secondary to Type 1 diabetits Chelsea Warren
Musculoskeletal and Neurovascular Systems shadow health
Documentation . She is following her reimen per her
endocrinologist. Allergies: NKDA, no latex or environment allergies.
Home Medications Insulin as part, subq daily per sliding scale at
meal time PMH DKA and was hospitalized Type 1 Diabetes Insulin
Glargine, subq daly dose
her adult horse from a height of two feet while the horse was
stationary. This occurred two days ago, and she has been having
intermittent pain inferior to her kneecap since the fall. Ned, her
father, present for exam, provides context and further clarification.
He xxxx but it really hurts.” Chelsea’s pain began before the fall.
She reports “Two weeks ago, I noticed that while
jumping/running/riding my left knee would start to hurt. I didn’t
really think about it because I’m getting taller. When I stopped to
rest it would go away.” Her father reports that she is not taking
acetaminophen, because the pain is relieved when she rests, and
she is not using the ice packs that he recommended because she
doesn’t like to touch her knee. She reports her pain as “really, really
bad” with activity, but simply “uncomfortable” at other times. She
didn’t report it because she was afraid her horse would get taken
away. Chelsea Warren Musculoskeletal and Neurovascular Systems
shadow health Documentation Ned affirms she uses helmets
regularly but declines to use knee pads due to peer pressure
regarding the way they make her look. Of particular importance, the
patient was discharged from the hospital 60 days ago with a
diagnosis of xxxxx Home Medications •Insulin glargine, sub q daily,
dose per endocrinology •Insulin as part, sub q sliding scale at
mealtime, dose per endocrinology Past Medical History
•Hospitalization: DKA •Diagnoses: Type 1 diabetes mellitus Social
History •Sexual History: has not started menstruating and is not
sexually active. •Physical activity: Rides horses three times weekly
for the last few years •Nutrition: healthy, carb-controlled diet •Social
support: Splits time with each parent every two weeks. Support
Student Documentation Model Documentation
from parents, content to stay with either one. Has close group of
friends, all girls. •Education: Attends school regularly 5th grade, on
track academically Review of Systems • Cardiac: Denies swelling in
the lower extremities. Denies ecchymosis in the lower extremities. •
Neurologic: Denies any abnormal gait, Denies any
numbness/tingling/weakness, Denies falls. • Musculoskeletal:
Denies pain with ambulation, affirms pain with
stairs/running/jumping/putting on pants, affirms pain with range of
motion activities involving the knee. • Hematologic: denies recurrent
bruising. • Dermatologic: Denies itching/rash/lesions.
10/16/22, 6:01 PM Chelsea Warren Musculoskeletal and Neurovascular Systems shadow health Documentation
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Student Documentation Model Documentation
Objective
VS: BP 114/76, O2 99% and posterior tibial pulse, HR 88%, Resp
Rate 20, Temp. 36.5C, BMI 18.5, Height 145cm, Weight 39kg
Physicial Exam General Survey: alert and oriented, sitting
comfortably in NAD, well groomed and xxxxxx tested with both
patellar and achilles at a +2 bilaterally. Musculoskeletal: Pt was able
to ambulate across the room with steady gait, squat with facial
grimace xxxx bilaterally without any abnormal findings noted.
Mucle strength was 5/5 on the hip and knees with pain observed
on the left knee as pt grimaced. Left tibial tuberosity was tender to
palpation Right tibial tuberosity was non tender to palpation with no
crepitus noted.
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Vital Signs BP: 114/76, O2 Sat: 99%, HR: 88 BPM, Resp. Rate: 20,
Temp: 36.5C, xxxxx speech is clear, appropriate, and pleasant.
Judgment and insight intact. •Cardiac: DP and PT and popliteal
pulses 2+ on palpation bilaterally. No peripheral extremity edema on
inspection. •Skin: Skin is warm, dry, intact throughout the body on
inspection. Skin is appropriate color for ethnicity. Good skin turgor.
No rashes or lesions present. •Neuro: Alert and oriented x xxxient is
able to ambulate across the room with steady gait. She is able to sit
upon and disembark exam table without difficulty. She performs a
full squat completely with observed facial grimacing and verbalizing
pain. Legs, hips, knees, ankles, and feet without edema or deformity
bilaterally on inspection. ROM xxxx ted: hips 5/5 bilaterally; knees
5/5 bilaterally with observed facial grimacing and verbalizing pain
when testing left knee; ankles 5/5 bilaterally. Patella non-tender to
palpation without crepitation or patellar instability bilaterally. Knee
joint stability assessed in supine position with stable knee joint
bilaterally on palpation. Chelsea Warren Musculoskeletal and
Neurovascular Systems shadow health Documentation No palpable
adiposities in the popliteal fossa bilaterally. Left tibial tuberosity
tender to palpation with a tibial prominence palpated and
verbalization of pain without crepitation. Right tibial tuberosity nontender to palpation without crepitation. Chelsea Warren
Musculoskeletal and Neurovascular Systems shadow health
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