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Musculoskeletal System Medical Record

Following is an abstract of a simulated patient medical record. Identify each italicized word. If the meaning doesn’t come right away, take apart the word. If you recognize the organ involved, use the context to help you figure out the full meaning. Terms are not limited to musculoskeletal system. Remember, this is a cumulative exercise! If you can’t think of the meaning, hover your cursor over the word for a tip.

A 62 year old male comes to his family physician complaining of pain in his right knee. He walks with a limp which he says is getting worse and is related to an old football injury. During the course of the examination he reveals that he also suffers from a “nervous bladder” with polyuriadysuria and nocturia, but denies hematuria. He smokes two packs a day, breaths are wheezy and he is short of breath, but denies hemoptysis.

Physical exam: right knee was swollen, warm and had limited range of motion which was painful to perform. Mild exercise increases wheezing and causes dyspnea. Examination of the heart size reveals cardiomegaly. No hepatomegaly or splenomegaly was found upon abdominal examination.

Current medication: Prevacid for gastroesophageal reflux disease, nitroglycerine for angina pectoris.

Past medical history: GERD diagnosed with esophagogastroduodenoscopy (EGD). Angina pectoris diagnosed with treadmill test, cardiac scan and cardiac catherization.

Past surgical history: orchidopexy for cryptorchidism at age nine, tonsillectomyappendectomy.

Family medical history: mother has chronic nephritis; will be starting dialysis.

Recommended treatments: refer to pulmonologist to evaluate possible emphysema. Refer to orthopaedist for arthroscopic evaluation of knee. Refer to urologist to evaluate for prostatic hypertrophy, possible cystoscopy. Office phlebotomist drew specimens for lab work.

Get a piece of paper and pencil and write down two column headings: “Signs” and “Symptoms.” Then take the following items and put them under the proper heading. You remember the difference between a sign and a symptom, right? You might want to review the context of these items in the case above before deciding.

Item: cardiomegaly, pain in right knee, right knee is swollen, nervous bladder.pr

In plain English

A 62 year old male comes to his family physician complaining of pain in his right knee. He walks with a limp which he says is getting worse and is related to an old football injury. During the course of the examination he reveals that he also suffers from a “nervous bladder” with frequent urination, painful/difficult urination and getting up at night to urinate, but denies blood in the urine. He smokes two packs a day, breaths are wheezy and he is short of breath, but denies coughing up blood.

Physical exam: right knee was swollen, warm and had limited range of motion which was painful to perform. Mild exercise increases wheezing and causes difficulty breathing. Examination of the heart size reveals an enlarged heart. No enlargement of the liver or spleen was found upon abdominal examination.

Current medication: Prevacid for severe heartburn, nitroglycerine for chest pain related to the heart.

Past medical history: GERD diagnosed with visual examination of the esophagus, stomach and duodenum with a fiberoptic instrument. Angina pectoris diagnosed with treadmill test, injecting a radioactive element into blood stream to evaluate heart structure and function and threading a hollow tube through arteries to the heart to inject dye opaque to X-rays to demonstrate coronary arteries.

Past surgical history: surgical fixation of the testis for undescended testicles at age nine, removal of tonsils, removal of appendix.

Family medical history: mother has chronic inflammation of kidneys; will be starting medical procedure cleansing waste from blood in kidney failure.

Recommended treatments: refer to specialist in lung diseases to evaluate possible destruction of lung membranes needed for oxygen exchange. Refer to specialist in musculoskeletal diseases for visualization of joints with a fiberoptic instrument (evaluation of knee). Refer to specialist in lower urinary tract diseases and diseases of the male reproductive tract to evaluate for enlargement of the prostate, possible visualization of the interior of the bladder with a fiberoptic instrument. Office technician or nurse trained to “cut into veins” to draw blood drew specimens for lab work.

By the way, what the patient complains of or describes are symptoms: knee hurts, frequent urination. What the doctor observes and/or measures are signs: right knee is swollen, enlarged heart.

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