Musculoskeletal (Part 2 of 2)

Advanced Physical Assessment & Diagnostic Reasoning - August '18, NURS 607 Return to Assignment Self-Reflection Activity Description: These prompts help you think more deeply about your performance in the assignment. Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician, and gives your instructor insight into your learning process. The more detail and depth you provide in your responses, the more you will benefit from this activity. Documentation Review Document: Provider Notes Student Response Model Documentation Subjective Chief Complaint: "Pain in lower back" HPI: Ms. Jones presents to the clinic with reports of lower back pain extending to her buttocks that started 3 days ago after she "tweaked" it when she was lifting a "heavy" box. Ms. Jones reports lifting 6 or 7 boxes before experiencing the back pain. She denies radiating pain, she reports pain as 5/10 on numeric pain scale. She reports the pain is "pretty constant" and has not changed over past three days. Denies numbness or tingling. Denies assocated bladder or bowel dysfunction. Pt reports taking OTC Advil for pain for the past three days every 5-6 hours. Ms. Jones unsure of dose of advil. She is here today due to pain continuing to interfere with daily activities. Medications: Advil 2 pills every 5-6 hours Flovent BID Allergies: Penicillin (rash) Cats (sneezing,itchy eyes,) Tobacco/ETOH/Drugs: Denies tobaccoo use, reports drinking socially with friends, no more than 10 drinks a month. Reports history of marijuana use but states, "I don't do that anymore" PMH: Childhood Illness: Asthma Adult Illness: Asthma Surgical: Denies OB/GYN: Last menstrual was one week agp, denies being sexually active, denies using birth control. Psychiatric: Health Maintenance: Received teatunus boooster 2 years ago 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 does state that she has difficulties with range of motion. She does state that the pain in her lower back has impacted her comfort while sleeping and sitting in class. She denies numbness, tingling, radiation, or bowel/bladder dysfunction. She Document: Provide... 9/7/2018 Musculoskeletal | In Progress Attempt | Shadow Health Student Response Model Documentation muscle disorders, Father died in car accident, mother living, medical history includes high cholesterol and hypertension, sister living, medical history of asthma, brother living, pt reports, "He's a little big" Personal/Social Hx: Currently enrolled in bachelor's degree program, works as a supervisor at Mid-American Copy and Ship, enjoys dacing and watching TV in spare time. Lives at home with mother and sister. ROS: General: Denies changes in weight, fatigue and recent fever Skin: Pt reports skin around neck getting darker and recent skin breakout Head: Denies headache, recent head injury, dizziness Eyes: Denies wearing glasses/contacts, reports last eye exam was as a child, reports blurry vision with reading Ears: Denies hearing difficulties Nose: Denies issues with nose Throat: Denies issues with chewing/swallowing, last dental exam a few years ago Neck: Denies swollen glands/neck stiffiness CV: Denies chest pain, reports chest tightness with asthma GI: Reports last bowel movement last night, denies changes in appetite Urinary: Denies difficulty urinating MSK: Denies joint pain, swelling or stiffiness. Reports low back pain that does not radiate, reports low back pain is making activities of daily living harder, reports " I can't really sit or move alot" Psychiatric: Denies thoughts or feeling down/depressed/hopeless Neurologic: Denies numbness tingling, denies changes in memory, denies fainting and seizure activity Endocrine: Denies heat/cold intolerance, denies family history of thyroid disorders.