Flexion extension lateral bending and rotation of the

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evidence of swollen joints or signs of infection.Flexion, extension, lateral bending, and rotation ofthe spine with reduced ROM - pain and difficulty.Bilateral upper extremity strength equal and 5/5 inneck, shoulders, elbows, wrists, hands. Bilaterallower extremity strength equal and 5/5 in hipflexors, knees, and ankles.AssessmentLower back pain strain as a result of liftingLow back muscle strain related to lifting
5/17/2018Musculoskeletal | Completed | Shadow Health4/4Student DocumentationStudent DocumentationModel DocumentationModel DocumentationPlanGive Ms. Jones streching back exercises andappropriate lifting technique hand outs increase her Ibuprofen to 600mg every 6 hours andTylenol as needed for break through pain. Also information on when to seek emergency caresuch as loss of bowel or bladder function or anylimitations in extremities Follow up in 2 weeks for re evaluation.Diagnostics • None at this time Medication • Initiate treatment with ibuprofen 600 mg by mouthevery six to eight hours with food as needed forpain for the next two weeks • She may use acetaminophen 500-1000 mg bymouth every 8 hours for breakthrough pain Education • Provide Ms. Jones with materials detailingstretching techniques for the lower back • Encourage Tina to be active and avoid prolongedperiods of lying down • Ms. Jones can also use adjunct therapy of topicalheat or ice per comfort TID-QID • Educate on proper body mechanics and liftingtechniques • 10-pound lifting restriction for 10 days Referral/Consultation • Referral to physical therapy if symptoms persist intwo weeks Follow-up Planning • Instruct Tina to seek emergent care including lossof bowel or bladder function, acute changes insensation of lower extremities, or limitations inmovement of lower extremities • Return to clinic in 2 weeks for follow up andevaluation of symptomsCommentsIf your instructor provides individual feedback on this assignment, it will appear here.© Shadow Health2018®

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