She presents today as the pain has continued and is interfering with her

She presents today as the pain has continued and is

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continued and is interfering with her activities of dailyliving.Social History: Ms. Jones’ job is mostly supervisory,although she does report that she may have to sit orstand for extended periods of time. She denies liftingat work or school. She states that her pain haslimited her activities of daily living. She denies use oftobacco, alcohol, and illicit drugs. She does notexercise.Review of Systems: General: Denies changes inweight, fatigue, weakness, fever, chills, and nightsweats. • Musculoskeletal: Denies muscle weakness,pain, joint instability, or swelling. She does state thatshe has difficulties with range of motion. She doesDocumentation / Electronic Health Record© Shadow Health2018®Musculoskeletal Physical Assessment Assignment | Completed | Shado...1 of 411/20/2018, 5:57 PM
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Student DocumentationStudent DocumentationModel DocumentationModel Documentationhaving issues.ROS:General: Patient denies any changes in weight. Shedenies any fever. She states that the pain hasinterrupted her sleep slightly.Musculoskeletal: Patient denies any muscle pain,weakness, and denies any joint pain or weakness.She also denies any swelling. She states that shehas trouble moving certain ways due to the pain inher back. This has effected her schooling and hersleeping. She denies any numbness or tingling, thepain does nto radiate, her bladder and bowelfunction is normal, no history of bone breaks orfracturesNeurologic: Patient denies any numbness, tingling,weakness, or lose of conciousness.state that the pain in her lower back has impactedher comfort while sleeping and sitting in class. Shedenies numbness, tingling, radiation, orbowel/bladder dysfunction. She denies previousmusculoskeletal injuries or fractures. • Neurologic:Denies loss of sensation, numbness, tingling,tremors, weakness, paralysis, fainting, blackouts, orseizures.ObjectiveMs. Jones is a nice and alert 28 year old africanamerican female. When at rest, she does not seemto be in pain, but when asked to move, her facialexpressions show that she is in pain as she is grittingher teeth and grimacing. She maintains eye contactand answers questions throughly and accurately.Visual inspection of the upper body foundsymmetrical neck with discoloration. Shoulders weresymetric bilaterally with no abnormal findings oneither. Arms were symmetric with no abnormalfindings on either arm. Elbows were symmetricbilaterally with no abnormal findings on either side.
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