Subjective: What details did the patient provide regarding her personal and medical history?

To prepare:

Use the Episodic/Focused Note Template found in the Learning Resources for this week to complete this assignment.
Select a patient that you examined during the last three weeks based on musculoskeletal conditions. With this patient in mind, address the following in a Focused Note:
Assignment:
Subjective: What details did the patient provide regarding her personal and medical history?
Objective: What observations did you make during the physical assessment?
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
Reflection notes: What would you do differently in a similar patient evaluation?

SAMPLE SOLUTION

Mrs. AJ is a 54 year old American female. She came to the office accompanied by her husband with chief complaints of increasing finger and knee joints pain on activity for the last six months, two weeks of swelling of the left wrist and stiffness of finger joints in the morning. She also reports general feeling of weakness. She reports to have been taking acetaminophen 500mg thrice daily for the last one month particularly on the days she experienced the most pain. There is no history of past illnesses and no drug allergies. She is a businesswoman. She admits to occasional cigarette smoking. Family history is positive for diabetes, her father and paternal grandfather are diabetic. On physical examination;

SKIN: Lumps around the elbows and finger joints
MUSCULOSKELETAL: Swelling of left wrist joint, deformed and tender finger…