3/29/2020 Musculoskeletal | Completed | Shadow Health
Your text here 1
Musculoskeletal Results | Turned In
Advanced Health Assessment - Clinical Replacement, NURS 520
Return to Assignment (/assignments/316008/)
Your Results Lab Pass (/assignment_attempts/6405147/lab_pass.p
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Provider Notes
Objective Data Collection
Document: Provider Notes
Education & Empathy
Documentation
Student Documentation Model Documentation
Student Survey
HPI: Ms. Jones presents to the clinic complaining of back pain th
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 o
box that caused her pain. The pain is in her low back and bilatera
buttocks, is a constant aching with stiffness, and does not radiate
The pain is aggravated by sitting (rates a 7/10) and decreased by
and lying flat on her back (pain of 3-4/10). The pain has not chan
over the past three days and she has treated with 2 over the cou
ibuprofen tablets every 5-6 hours. Her current pain is a 5/10, but
Subjective states that the ibuprofen can decrease her pain to 2-3/10. She de
numbness, tingling, muscle weakness, bowel or bladder
Ms. Tina Jones is an obese 28 year old African American who came
incontinence. She presents today as the pain has continued and
to the clinic with complaints of lower back pain and buttocks that
interfering with her activities of daily living.
started 3 days ago after lifting a heavy box. She states the pain is
constant with aching and stiffness, but does not radiate. The pain is
Social History: Ms. Jones’ job is mostly supervisory, although she
aggravated by sitting and is decreased with rest and lying down, She
does report that she may have to sit or stand for extended period
said it hurts more when reaching and bending. She is allergic to cats
time. She denies lifting at work or school. She states that her pai
and dust. She is allergic to PCN. PCN gives her diffuse rash.
has limited her activities of daily living. She denies use of tobacco
Musculoskeletal: denies joint pain, trauma, fractures, dislocations,
alcohol, and illicit drugs. She does not exercise.
sprain. No family history of gout, arthritis, and osteoporosis
Review of Systems: General: Denies changes in weight, fatigue,
weakness, fever, chills, and night sweats. • Musculoskeletal: Den
muscle weakness, pain, joint instability, or swelling. She does sta
that she has difficulties with range of motion. She does state that
pain in her lower back has impacted her comfort while sleeping a
sitting in class. She denies numbness, tingling, radiation, or
bowel/bladder dysfunction. She denies previous musculoskeletal
injuries or fractures. • Neurologic: Denies loss of sensation,
numbness, tingling, tremors, weakness, paralysis, fainting, black
or seizures.
This study source was downloaded by 100000832361371 from CourseHero.com on 02-07-2022 09:56:22 GMT -06:00
https://app.shadowhealth.com/assignment_attempts/6405147 1/2
https://www.coursehero.com/file/58840802/TINA-JONES-DOCUMENTATION-Musculoskeletal-Completed-Shadow-Healthpdf/
Your text here 1
Musculoskeletal Results | Turned In
Advanced Health Assessment - Clinical Replacement, NURS 520
Return to Assignment (/assignments/316008/)
Your Results Lab Pass (/assignment_attempts/6405147/lab_pass.p
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Provider Notes
Objective Data Collection
Document: Provider Notes
Education & Empathy
Documentation
Student Documentation Model Documentation
Student Survey
HPI: Ms. Jones presents to the clinic complaining of back pain th
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 o
box that caused her pain. The pain is in her low back and bilatera
buttocks, is a constant aching with stiffness, and does not radiate
The pain is aggravated by sitting (rates a 7/10) and decreased by
and lying flat on her back (pain of 3-4/10). The pain has not chan
over the past three days and she has treated with 2 over the cou
ibuprofen tablets every 5-6 hours. Her current pain is a 5/10, but
Subjective states that the ibuprofen can decrease her pain to 2-3/10. She de
numbness, tingling, muscle weakness, bowel or bladder
Ms. Tina Jones is an obese 28 year old African American who came
incontinence. She presents today as the pain has continued and
to the clinic with complaints of lower back pain and buttocks that
interfering with her activities of daily living.
started 3 days ago after lifting a heavy box. She states the pain is
constant with aching and stiffness, but does not radiate. The pain is
Social History: Ms. Jones’ job is mostly supervisory, although she
aggravated by sitting and is decreased with rest and lying down, She
does report that she may have to sit or stand for extended period
said it hurts more when reaching and bending. She is allergic to cats
time. She denies lifting at work or school. She states that her pai
and dust. She is allergic to PCN. PCN gives her diffuse rash.
has limited her activities of daily living. She denies use of tobacco
Musculoskeletal: denies joint pain, trauma, fractures, dislocations,
alcohol, and illicit drugs. She does not exercise.
sprain. No family history of gout, arthritis, and osteoporosis
Review of Systems: General: Denies changes in weight, fatigue,
weakness, fever, chills, and night sweats. • Musculoskeletal: Den
muscle weakness, pain, joint instability, or swelling. She does sta
that she has difficulties with range of motion. She does state that
pain in her lower back has impacted her comfort while sleeping a
sitting in class. She denies numbness, tingling, radiation, or
bowel/bladder dysfunction. She denies previous musculoskeletal
injuries or fractures. • Neurologic: Denies loss of sensation,
numbness, tingling, tremors, weakness, paralysis, fainting, black
or seizures.
This study source was downloaded by 100000832361371 from CourseHero.com on 02-07-2022 09:56:22 GMT -06:00
https://app.shadowhealth.com/assignment_attempts/6405147 1/2
https://www.coursehero.com/file/58840802/TINA-JONES-DOCUMENTATION-Musculoskeletal-Completed-Shadow-Healthpdf/
