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Musculoskeletal Physical Assessment Assignment Results | Turned In Advanced Health Assessment - Chamberlain, NR509-October-2018 Return to Assignment$10.49
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Musculoskeletal Physical Assessment Assignment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-October-2018
Return to Assignment
Your Results Lab Pass
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Provider Notes
Objective Data Collection
Education & Empathy Document: Provider Notes
Documentation
Student Documentation Model Documentation
Lifespan
Subjective
Review Questions HPI: Ms. Jones presents to the clinic complaining of
TJ, 28, AA back pain that began 3 days ago after she “tweaked
Self-Reflection it” while lifting a heavy box while helping a friend
CC: low back pain move. She states that lifted several boxes before
HPI: this event without incident and does not know the
Onset: Sudden, 3 days ago when bending over and weight of the box that caused her pain. The pain is in
lifting a box, helping a friend move her low back and bilateral buttocks, is a constant
Duration: 3 days aching with stiffness, and does not radiate. The pain
Characteristics: Sharp twinge, then achy pain 5/10 at is aggravated by sitting (rates a 7/10) and decreased
its worst, 2-3 /10 with medication. Pain in lower by rest and lying flat on her back (pain of 3-4/10).
back/upper buttocks, sore to touch. Denies tingling, The pain has not changed over the past three days
muscle weakness, radiation, bowel or bladder and she has treated with 2 over the counter
incontinence. Pain interferes with ADL's including ibuprofen tablets every 5-6 hours. Her current pain is
sleep, unable to sit for long periods of time. a 5/10, but she states that the ibuprofen can
Aggravating factors: sitting up, moving around decrease her pain to 2-3/10. She denies numbness,
Relieving factors: Lying flat tingling, muscle weakness, bowel or bladder
Treatment: Advil incontinence. She presents today as the pain has
continued and is interfering with her activities of daily
Medications: living.
Ibuprofen 200mg tab, 400mg (2 tabs) po q6h prn
pain, last used this morning Social History: Ms. Jones’ job is mostly supervisory,
Flovent 110mcg 2 puffs bid, last used this morning although she does report that she may have to sit or
Albuterol 90mcg 2 puffs prn shortness of breath stand for extended periods of time. She denies lifting
Tylenol 500mg, 500-1000mg (1-2 tabs) po qhs prn at work or school. She states that her pain has
headache limited her activities of daily living. She denies use of
tobacco, alcohol, and illicit drugs. She does not
Allergies: exercise.
Cats: sneezing, itchy eyes, asthma exacerbation
Penicillin: rash, hives Review of Systems: General: Denies changes in
Dust: asthma exacerbation weight, fatigue, weakness, fever, chills, and night
sweats. • Musculoskeletal: Denies muscle
PMHx:
weakness, pain, joint instability, or swelling. She
https://www.coursehero.com/file/35634800A/Mstuhsmcualoskeletal-Physical-Assessment-Assignment-Documentatidoonepdsfs/ tate that she has difficulties with range
of
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