Allergies: PCN, cats and dust , reoprts no new allergies PMHx asthma and diabetes, denies any surgeries, or fractures Fam Hx: denied any family history of musculoskeletal problems osteoporosis arthritis, bone cancer or degenerative muscle disease ROS: 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 the box 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 rest and 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 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.
5/17/2018 Musculoskeletal | Completed | Shadow Health 3/4 Student Documentation Student Documentation Model Documentation Model Documentation Objective Tina Jones is a 28 year old African American female VS Height 170cm Weight: 87kg BMI: 30.1 TEMP: 99.2
- Fall '15
- Human Anatomy, Ms. Jones