musculoskeletal model note.docx - chief complaint Pain in lower back Onset Three days go while helping friend move box Location Lower back and top of

musculoskeletal model note.docx - chief complaint Pain in...

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chief complaint: Pain in lower back Onset: Three days go while helping friend move box. Location: Lower back and top of buttocks bilaterally Duration: constant since accident Characteristics: initially described as a twinge of sharp pain now it is described as an ache and a 5/10 on the pain scale. Aggravating Factors: Pain worsens upon movement, bending, reaching, and sitting. Relieving factors: Lying supine Treatment: Advil and lying supine Current medications: Flovent MDI 2puffs BID as a maintenance inhaler Albuterol 2 puffs Q4H prn shortness of breath as a rescue inhaler Advil 200mg 2 tabs every 5-6 hours prn back pain Allergies: Dust causes asthma exacerbation Catscause itchy eyes, rhinorrhea, and asthma exacerbation Penicillin causes rash and hives. PMH:Diabtes diagnosed at age 24 and asthma diagnosed at age 2.5 years old. Denies surgical history. Last tetanus booster was two years ago. Social history: Patient is a single black woman, who is pursuing her bacchelor's degree in acounting. She works as a supervisor at mid american ship and copy. Patient states she drinks two to three drinks during social gatherings but usually does not drink throughout the week. Patient denies tobacco use. Patient states she uses a seat belt in the car. Family history: no pertient family history to today's visit. Mother is currently alive and suffers from hypertension and hypercholesterolemia Father is deceased suffered from hypertension and hypercholesterolemia Brother is described as being overweight sister is 14 and suffers from asthma Review of systems: Constitutional: patient denies weight loss, fever, chills, weakness or fatigue HEENT: positive for blurred vision when reading for long periods. Patient denies visual loss, double vision hearing loss sneezing congestion runny nose and sore throat. Skin: 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 thebox 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 restand 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 deniesnumbness, tingling, muscle weakness, bowel or bladder incontinence.
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