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Shadow Health Musculoskeletal Tina
Jones 100% Correct
1. chief complaint: -reports low back pain
-describes injury as a "tweak to back"
2. onset of pain: -original injury occurred 3 days ago
-sudden onset -happed when lifting heavy box
3. location of pain: -located in low back and butt
-does not radiate or migrate -denies neck pain -denies pain between shoulder blades -reports pain is same on both sides of back
4. frequency and duration of pain: -pain lasted 3 days
-constant pain
5. severity of pain: -current pain "pretty bad"
-original injury as 6 or 7/ -current pain 5/
6. character of pain: -pain at the onset was sharp
-aching pain -denies burning pain
-back is sore to touch -pain accompanied by stiffness
7. aggravating factors: -feels least comfortable when sitting
-some pain with movement such as walking or bending
8. relieving factors: -slight pain relief with rest
-feels most comfortable when lying flat on back -denies hear or ice
9. impact of pain of ADL: -pain interferes with ADLs
-slight sleep disturbance -no exercise since accident -receiving help from mom and sister
10. confirmed use of meds: -confirms meds
-increased ibuprofen use for pain
11. followed up on ibuprofen: -take for past 3 days
-last dose ~5 hours ago -takes 2 at a time -takes every 5-6 hours per instructions -unsure of dose, not extra strenght -provides relief for several hours
12. confirms allergies: no new allergies reported
13. possible contributing factors in health history: -no hx of previous back
pain/injury -no hx of severe trauma
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 motion. She does state that the pain in her lower back has impacted her comfort while sleeping and sitting in class. She denies numbness, tingling, radiation, or bowel/bladder dysfunction. She denies previous musculoskeletal injuries or fractures. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures.
20. objective: General: Ms. Jones is a pleasant, obese 28-year-old African Amer- ican
woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. Musculoskeletal: Bilateral upper extremities without muscle atrophy or joint deformity. Bilateral upper extremities with full range of motion of shoulder, elbow, and wrist. No evidence of swollen joints or signs of infection. Bilateral lower extremities without muscle atrophy or joint deformity, full range of motion of bilateral hips, knees, and ankles. No evidence of swollen joints or signs of infection. Flexion, extension, lateral bending, and rotation of the spine with reduced ROM - pain and difficulty. Bilateral upper extremity strength equal and 5/5 in neck, shoulders, elbows, wrists, hands. Bilateral lower extremity strength equal and 5/5 in hip flexors, knees, and ankles.
21. assessment: low back muscle strain related to lifting
22. plan: Provide Ms. Jones with materials detailing stretching techniques for the
lower back. • Initiate treatment with ibuprofen 600 mg by mouth every six to
