NURS 607: Musculoskeletal Results | Turned In Advanced Physical Assessment & Diagnostic Reasoning.

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Musculoskeletal Results | Turned In Advanced Physical Assessment & Diagnostic Reasoning - August '18, NURS 607 Return to Assignment Your Results Document: Provider Notes Document: Provider Notes ... Student Documentation Model Documentation Subjective Chief Complaint: "Pain in lower back" HPI: Ms. Jones presents to the clinic with reports of lower back pain extending to her buttocks that started 3 days ago after she "tweaked" it when she was lifting a "heavy" box. Ms. Jones reports lifting 6 or 7 boxes before experiencing the back pain. She denies radiating pain, she reports pain as 5/10 on numeric pain scale. She reports the pain is "pretty constant" and has not changed over past three days. Denies numbness or tingling. Denies assocated bladder or bowel dysfunction. Pt reports taking OTC Advil for pain for the past three days every 5-6 hours. Ms. Jones unsure of dose of advil. She is here today due to pain continuing to interfere with daily activities. Medications: Advil 2 pills every 5-6 hours Flovent BID Allergies: Penicillin (rash) Cats (sneezing,itchy eyes,) Tobacco/ETOH/Drugs: Denies tobaccoo use, reports drinking socially with friends, no more than 10 drinks a month. Reports history of marijuana use but states, "I don't do that anymore" PMH: Childhood Illness: Asthma Adult Illness: Asthma Surgical: Denies OB/GYN: Last menstrual was one week agp, denies HPI: Ms. Jones presents to the clinic complaining of back pain that began 3 days ago after she “tweaked it” while lifting a heavy box while helping a friend move. She states that lifted several boxes before this event without incident and does not know the weight of the box that caused her pain. The pain is in her low back and bilateral buttocks, is a constant aching with stiffness, and does not radiate. The pain is aggravated by sitting (rates a 7/10) and decreased by rest and lying flat on her back (pain of 3-4/10). The pain has not changed over the past three days and she has treated with 2 over the counter ibuprofen tablets every 5-6 hours. Her current pain is a 5/10, but she states that the ibuprofen can decrease her pain to 2-3/10. She denies numbness, tingling, muscle weakness, bowel or bladder incontinence. She presents today as the pain has continued and is interfering with her activities of daily living. Social History: Ms. Jones’ job is mostly supervisory, although she does report that she may have to sit or stand for extended periods of time. She denies lifting at work or school. She states that her pain has limited her activities of daily living. She denies use of tobacco, alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Musculoskeletal: Denies muscle weakness, pain, joint instability, or swelling. She does state that she has difficulties with range of [Show More]

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