WEEK 3 MUSCULAR.pdf - Musculoskeletal | Completed | Shadow Health Musculoskeletal Results | Turned In Advanced Health Assessment Chamberlain

WEEK 3 MUSCULAR.pdf - Musculoskeletal | Completed | Shadow...

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5/17/2018 Musculoskeletal | Completed | Shadow Health 1/4 Musculoskeletal Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Lab Pass Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Lifespan Review Questions Self-Reflection Documentation / Electronic Health Record This study resource was shared via CourseHero.com
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5/17/2018 Musculoskeletal | Completed | Shadow Health 2/4 Student Documentation Student Documentation Model Documentation Model Documentation Subjective Tina Jones is a 28 year old African American female With a chief complaint of lower back pain vs Ht:170cm WT: 87kg BMI: 30.1 Temp: 99.2 B/P 141/80 HR: 88 RR: 14 O2SAT: 99% RA CC: Ms Jones states" she is having pain in her lower back it really hurts and does not seem to go away." Back pain started 3 days ago when she "tweeked" back while lifting a box. A notice from the lower back to the top of the top of the buttock. Denies any radiation or neck pain. pain is consistent in both sides of the back. Reporting her pain is constant for the last 3 days.5/10 on pain scale. inital pain was a6/7 out of 10. Using advil for pain every 5 to 6 hours two Tablets by mouth. Describes pain a "ache". Denies any burning or stiffness in the back but sore to touch. Reports being less comfortable when sitting able to walk. Relieving factors of back pain are Advil and most comfortable on back. Denies any heat or ice application to the back. Report interfering with activities of daily living light sleep disturbance, denies missing work or school due to pain. Denies any heavy lifting alone at work but if it is heavy does not do it alone. Denies any fever chills night sweats nausea or vomiting. exhausted at the end of the day. Current Medications: Flovent 2 puffs BID proventil 90mcg MDI 2 puffs q4Hprn lasted used " few months" , Tylenol 500-1000mg po prn headaches. Denies any muscle weakness joint pain joint swelling for joint stiffness. Denies any headaches due to injury, only headaches when studying. Denies any numbness or tingling, bowel or bladder changes. No reports of dizziness or lightheadedness.
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