NR 509 Musculoskeletal Documentation Shadow.pdf - Musculoskeletal Physical Assessment Assignment | Completed | Shado 1 of 4

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Musculoskeletal Physical Assessment Assignment Results | Turned InAdvanced Health Assessment - Chamberlain, NR509-October-2018Return to AssignmentYour ResultsOverviewTranscriptSubjective Data CollectionObjective Data CollectionEducation & EmpathyDocumentationLifespanReview QuestionsSelf-ReflectionDocument: Provider NotesDocument: Provider NotesStudent DocumentationStudent DocumentationModel DocumentationModel DocumentationSubjectiveCC: lower back painHPI: Tina came into the office with complaints ofback pain that started about 3 days ago when shewas lifting a box. Patient states that "she tweakedher back" and that it felt like a sharp pain as it washappening. After that it has settled into a dul ache forthe past three days. The pain is in her lower backand the top of her buttocks. She claims that it isconstant and is accompanied by some stiffness, butit does not radiate. Sitting for long periods of timeaggravates the pain, but lying down helps relieve itslightly. She rates the pain while sitting at a 7 out of10 and the pain while resting at a 4 out of 10. Thepain has not changed. She has been taking OTCibuprofen, but she does not know the exact dosagesaying it was "2 tablets of regular strength" every 5or so hours. Her last dosage was 5 hours before herappointment. She rates the pain while on ibuprofenhas a 3 out of 10. Her current pain at the time of theappintment was 5 out of 10. Patient states that thepain is beginning to interfere with her daily activities.Social History: Tina is a student who spends most ofher day sitting, but she does not typically do anyheavy lifting. She has not had to miss any work orschool, but sitting in class really aggravated her backpain. There is no family history of back issues.Patient does not smoke, do drugs, and only drinksoccasionally. She has family to help her do simplethings around the house as long as her back isHPI: Ms. Jones presents to the clinic complaining ofback pain that began 3 days ago after she “tweakedit” while lifting a heavy box while helping a friendmove. She states that lifted several boxes before thisevent without incident and does not know the weightof the box that caused her pain. The pain is in herlow back and bilateral buttocks, is a constant achingwith stiffness, and does not radiate. The pain isaggravated by sitting (rates a 7/10) and decreasedby rest and lying flat on her back (pain of 3-4/10).The pain has not changed over the past three daysand she has treated with 2 over the counteribuprofen tablets every 5-6 hours. Her current pain isa 5/10, but she states that the ibuprofen candecrease her pain to 2-3/10. She denies numbness,tingling, muscle weakness, bowel or bladderincontinence. She presents today as the pain has
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