NUR 3010 Esther Parks Focused Exam Abdominal Pain Subjective

Musculoskeletal Physical Assessment Assignment Results | Turned In Advanced Health Assessment - Chamberlain, NR509-October-2018 Return to Assignment Your Results Lab Pass Documentation / Electronic Health Record Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Subjective TJ, 28, AA CC: low back pain HPI: Onset: Sudden, 3 days ago when bending over and lifting a box, helping a friend move Duration: 3 days Characteristics: Sharp twinge, then achy pain 5/10 at its worst, 2-3 /10 with medication. Pain in lower back/upper buttocks, sore to touch. Denies tingling, muscle weakness, radiation, bowel or bladder incontinence. Pain interferes with ADL's including sleep, unable to sit for long periods of time. Aggravating factors: sitting up, moving around Relieving factors: Lying flat Treatment: Advil Medications: Ibuprofen 200mg tab, 400mg (2 tabs) po q6h prn pain, last used this morning Flovent 110mcg 2 puffs bid, last used this morning Albuterol 90mcg 2 puffs prn shortness of breath Tylenol 500mg, 500-1000mg (1-2 tabs) po qhs prn headache Allergies: Cats: sneezing, itchy eyes, asthma exacerbation Penicillin: rash, hives Dust: asthma exacerbation PMHx: 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 Diabetes Type 2 Tetanus booster 2 years ago Influenza immunization 5-6 years ago Pneumococcal vaccine-unsure Soc Hx: Denies tobacco use Social alcohol use Denies current illegal drug use Denies taking unprescribed medications +Seatbelt use Fam Hx: No history of back pain, muscle problems, bone problems, osteoporosis ROS: General: Denies any weight change, fever, chills, weakness, chills, or night sweats. Pt lying down on exam table. Maintains eye contact throughout interview. Appears somewhat jittery. Neurological: No changes in headaches since injury, states occasional headache when reading. States walking "isn't great". No dizziness, syncope, paralysis, ataxia, numbness or tingling. Denies bowel or bladder incontinence Musculoskeletal: C/O muscle pain/stiffness in back, denies any other muscle pain. Denies muscle weakness, fatigue or edema. Denies numbness, tingling, radiation, tremors, bowel/bladder incontinence. Denies previous back problems or musculoskeletal injuries.