ShadowHealth Musculoskeletal Tina Jones

ShadowHealth Musculoskeletal Tina Jones chief complaint Correct Answer: -reports low back pain -describes injury as a "tweak to back" onset of pain Correct Answer: -original injury occurred 3 days ago -sudden onset -happed when lifting heavy box location of pain Correct Answer: -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 Correct Answer: -pain lasted 3 days -constant pain severity of pain Correct Answer: -current pain "pretty bad" -original injury as 6 or 7/10 -current pain 5/10 character of pain Correct Answer: -pain at the onset was sharp -aching pain -denies burning pain -back is sore to touch -pain accompanied by stiffness aggravating factors Correct Answer: -feels least comfortable when sitting -some pain with movement such as walking or bending relieving factors Correct Answer: -slight pain relief with rest -feels most comfortable when lying flat on back -denies hear or ice impact of pain of ADL Correct Answer: -pain interferes with ADLs -slight sleep disturbance -no exercise since accident -receiving help from mom and sister confirmed use of meds Correct Answer: -confirms meds -increased ibuprofen use for pain followed up on ibuprofen Correct Answer: -take for past 3 days -last dose ~5 hours ago -takes 2 at a time -takes every 5-6 hours per instructions -unsure of dose, not extra strenght -provides relief for several hours confirms allergies Correct Answer: no new allergies reported possible contributing factors in health history Correct Answer: -no hx of previous back pain/injury -no hx of severe trauma -denies past surgery -denies increase in alcohol use since injury -denies hx of fractures -denies heavy lifting at work impact of pain on income and education Correct Answer: -no missed work due to pain -no missed school due to pain, but discomfort sitting in class general symptoms Correct Answer: -denies fever, chills, night sweats, NV -low energy level ROS for MSK system Correct Answer: -denies muscle weakness -denies joint pain, swelling, redness, stiffness ROS for neuro system Correct Answer: -denies headache r/t injury -denies numbness, tingling, dizziness, light-headedness, disequilibrium -denies changes to bowel or bladder function family history Correct Answer: -denies hx of general MSK problems -denies osteoporosis -denies arthritis -denies bone cancer/disease -denies degenerative muscle disease subjective Correct Answer: 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