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Document a History and Physical Assessment of the Musculoskeletal System
Department of Nursing, Rasmussen University
NUR2180: Physical Assessment
Prof. Laura Buchanan, MSN
April 23, 2021
Subjective
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39-year-old Hispanic male chief complaint right ankle is in pain. Patient rates pain on right ankle
at a 4 out of 10. Patient states using cold compress and elevating foot lowers pain lowers pain to
right ankle to 2 out of 10. Patient states ambulation makes the pain worse at a 7 out of 10.
Patient states pain is a throbbing pain. Patient’s pain does not radiate it is localized. Patient states
this pain started last night at 20:00. Patient was playing basketball and landed badly, patient
states they rolled their right ankle. Patient has no history of joint pain, osteoporosis, or arthritis.
Patient has no history of broken bones or bone deformities. Patient states they are still able to
perform their activities of daily living (ADL). Patient states they have no allergies. Patient states
they are not taking any medications.
Objective
On examination, patient has full range of motion on all extremities except to right ankle. Patients
has no swelling or pain to temporal mandibular joint. No tenderness or warmness to the temporal
mandibular joint upon palpation. Neck is symmetrical, no involuntary movement, and no
discoloring to neck coloring is consistent with face. No warmth or tenderness to neck upon
palpation on patient’s neck. Strength of the patient’s neck is at a 5 out of 5. Patient’s spine is
symmetrical with no sign of redness, swelling, deformities, or changes of spinal alignment.
Patient’s shoulders, elbows, wrists, and hands have full range of motion with no difficulty upon
movement. No redness, swelling, deformities, lesions, masses on patient’s upper extremities.
Patient’s shoulders, elbows, wrists, and hands strength are at a 5 out of [Link] hips no
tenderness or warmth upon palpation. Patient’s gait is compromised to due to imbalance; most of
the weight is placed on left leg due to right ankle pain. Patients hip strength is a 5 out of 5.
Patient’s color of knees is consistent throughout, no redness, or lesions upon inspection. No
masses, tenderness, or deformities felt upon palpation of knees. Patient has a 5 out 5 on
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extension and flexion of the knees. Patient’s knees are at a 5 out 5. Patient upon inspection of
right ankle signs of mild nonpitting edema with mild erythema on right ankle. Patient’s right
ankle is warm and tender on lateral section of the ankle upon palpation. Patient’s range of motion
(ROM) is limited on right ankle at a 3 out of 5 due to difficulty with dorsal and plantar flexion.
Patient’s right ankle strength is at a 2 out of 5. Patient’s left ankle has no redness, swelling,
deformities upon inspection. Patient’s left ankle has no tenderness or warmth upon palpation.
Patient’s ROM is 5 out of 5 on left ankle. Patient’s left ankle strength is at a 5 out of 5.
Risk Factors
Due to the condition of the patient’s right ankle their gait is imbalanced. Patient may be at risk
for falls. Patient’s impaired gait may cause strain on other joints in the body. Patient is at risk of
weight gain by being inactive due to right ankle injury. Patient is at risk for future injury to right
ankle without proper care.
Abnormal Findings
Abnormalities were found on the right ankle. Patient’s right ankle has redness and swelling.
Patient’s right ankle had a limited ROM and strength .