ShadowHealth Musculoskeletal Tina
Jones Graded A+
chief complaint - ans -reports low back pain
-describes injury as a "tweak to back"
onset of pain - ans -original injury occurred 3 days ago
-sudden onset
-happed when lifting heavy box
location of pain - ans -located in low back and butt
-does not radiate or migrate
-denies neck pain
-denies pain between shoulder blades
-reports pain is same on both sides of back
frequency and duration of pain - ans -pain lasted 3 days
-constant pain
severity of pain - ans -current pain "pretty bad"
, -original injury as 6 or 7/10
-current pain 5/10
character of pain - ans -pain at the onset was sharp
-aching pain
-denies burning pain
-back is sore to touch
-pain accompanied by stiffness
aggravating factors - ans -feels least comfortable when sitting
-some pain with movement such as walking or bending
relieving factors - ans -slight pain relief with rest
-feels most comfortable when lying flat on back
-denies hear or ice
impact of pain of ADL - ans -pain interferes with ADLs
-slight sleep disturbance
-no exercise since accident
-receiving help from mom and sister
confirmed use of meds - ans -confirms meds
-increased ibuprofen use for pain
followed up on ibuprofen - ans -take for past 3 days
Jones Graded A+
chief complaint - ans -reports low back pain
-describes injury as a "tweak to back"
onset of pain - ans -original injury occurred 3 days ago
-sudden onset
-happed when lifting heavy box
location of pain - ans -located in low back and butt
-does not radiate or migrate
-denies neck pain
-denies pain between shoulder blades
-reports pain is same on both sides of back
frequency and duration of pain - ans -pain lasted 3 days
-constant pain
severity of pain - ans -current pain "pretty bad"
, -original injury as 6 or 7/10
-current pain 5/10
character of pain - ans -pain at the onset was sharp
-aching pain
-denies burning pain
-back is sore to touch
-pain accompanied by stiffness
aggravating factors - ans -feels least comfortable when sitting
-some pain with movement such as walking or bending
relieving factors - ans -slight pain relief with rest
-feels most comfortable when lying flat on back
-denies hear or ice
impact of pain of ADL - ans -pain interferes with ADLs
-slight sleep disturbance
-no exercise since accident
-receiving help from mom and sister
confirmed use of meds - ans -confirms meds
-increased ibuprofen use for pain
followed up on ibuprofen - ans -take for past 3 days
