Bilateral upper extremity strength equal and 55 in neck shoulders elbows wrists

Bilateral upper extremity strength equal and 55 in

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Bilateral upper extremity strength equal and 5/5 in neck, shoulders, elbows, wrists, hands. Bilateral lower extremity strength equal and 5/5 in hip flexors, knees, and ankles. Assessment Primary: S39.012A Strain of muscle, fascia and tendon of lower back, initial encounter: r/t lifting a box Possible: M54.5 Low back pain, Lumbago NOS M54.9 Dorsalgia, unspecified Low back muscle strain related to lifting
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Student Documentation Student Documentation Model Documentation Model Documentation Plan Diagnostic: none at this time Medications: Ibuprofen 800mg po q6-8 hours prn pain, take with food Tylenol 500-1000mg po q8h prn pain Education: Encourage journaling of symptoms and associated pain Low back stretches Heat/Ice therapy 3-4 times a day prn pain Proper body mechanics when lifting Referral/ Consults: none at this time Follow up: 2 weeks for evaluation of symptoms When to seek immediate medical care: Any numbness or tingling in extremities, loss of bowel or bladder control, difficulty moving arms or legs, inability to ambulate. Diagnostics • None at this time Medication • Initiate treatment with ibuprofen 600 mg by mouth every six to eight hours with food as needed for pain for the next two weeks • She may use acetaminophen 500-1000 mg by mouth every 8 hours for breakthrough pain Education • Provide Ms. Jones with materials detailing stretching techniques for the lower back • Encourage Tina to be active and avoid prolonged periods of lying down • Ms. Jones can also use adjunct therapy of topical heat or ice per comfort TID-QID • Educate on proper body mechanics and lifting techniques • 10-pound lifting restriction for 10 days Referral/Consultation • Referral to physical therapy if symptoms persist in two weeks Follow-up Planning • Instruct Tina to seek emergent care including loss of bowel or bladder function, acute changes in sensation of lower extremities, or limitations in movement of lower extremities • Return to clinic in 2 weeks for follow up and evaluation of symptoms Comments If your instructor provides individual feedback on this assignment, it will appear here. © Shadow Health 2018 ®
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