Musculoskeletal System Documentation for Female Patient Assignment

Assignment Task

This is a physical assessment documentation. I want a nurse/nursing student to add more to my documentation and write it out in details. I did my assignment on a female patient. The documentation is about Musculoskeletal System.

Case Study

WL, a 38yr old, appears stated age, alert, and orientated 4. Airway patency, eupneic breathing of 13 breathes/min, sits and stands erect with no difficulty, no deformities, skin is nice and smooth, pink in color, warm evenly, and dry, skin turgor symmetrical, dresses nice clean cloths fit for the occasion, body build; muscular lean, mobility; walks in the room with no sign of staggering, upper extremities; temporomandibular joint; no swelling, no lesions, no pain, no nodules present upon palpation, no clicking, no grating or pain when opening and closing the mouth, muscles of mastication intact, no swelling, no pain, no swelling, no tenderness upon palpation of the muscles and when clenching teeth, Cervical spine; straight and the head is erect, spinous processes feel firm with no muscle spasm upon palpation, no sign of deformities, head; good strength, performs all range of motion without any pain, like chin to chest, chin to shoulder and chin toward each shoulder, pushes against resistance with the hand placed on cheek bilaterally, shoulders; muscle equal posteriorly and anteriorly upon inspection, no redness, no muscular atrophy, deformity, or swelling present, no muscular spasm, swelling, heat, or tenderness present upon palpation, good range of motion, no crepitation, shrugs shoulder with no pain, pushes against resistance with ease, elbow; upon inspection, both elbows flex and extend bilaterally, no deformities, no swelling, no nodules, no lumps, good strength in both, flexes and extends against resistance with ease, no pain, wrist and hand; no tenderness, no swelling, no deformity, no redness on both dorsal and palmar sides, fingers lie straight as forearm, skin is smooth, knuckle wrinkle present, no swelling , or nodules, muscles are even on the thumbs, no fluid present, upon palpation, joint surfaces are smooth, no swelling, no bogginess, nodules or tenderness, good range of motion, palmar flexion, abducts fingers, makes a fist, thumb touches each finger, and base of little finger bilaterally, flexes and extends fingers , no presence of carpel tunnel, lower extremities; hip joints symmetrical at the back while standing, even gait, legs align, no tenderness or crepitation upon palpation, arms same space, good range of motion, hip flexion with no pain, walks forward on toes and back on heels, no signs of herniated disk, knees; skin is smooth, with no swelling, or lesions, even color, even leg alignment, no swelling, or fullness on either side of knee cap, no warmth in the joint, no signs of atrophy in the quadricep muscles, good range of motion, extends and flexes each knee with no pain, maintains knee flexion against resistance, ankle and foot; upon inspection, feet align with knee, toes point straight and flat on floor bilaterally, clean toenails, even in color, hair evenly distributed, no swelling, no nodules, no tenderness, or lesions, good range of motion, dorsiflexes, plantar flexes, invert and evert with no pain noted, strength test; maintains dorsiflexion and plantar flexion against resistance, tolerated the examination and assessment well, demonstrated how to perform range of motion, was able to return demonstrate, advise on benefits of exercise, advise to exercise with caution when doing range of motion, demonstrated how to inspect and palpate for any abnormalities, left in a comfortable position.

This Nursing has been solved by our PhD Experts at My Uni Paper.