solution
chief complaint
-reports low back pain
-describes injury as a "tweak to back"
onset of pain
-original injury occurred 3 days ago
-sudden onset
-happed when lifting heavy box
location of pain
-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
-pain lasted 3 days
-constant pain
severity of pain
-current pain "pretty bad"
-original injury as 6 or 7/10
-current pain 5/10
character of pain
-pain at the onset was sharp
-aching pain
-denies burning pain
-back is sore to touch
-pain accompanied by stiffness
aggravating factors
-feels least comfortable when sitting
-some pain with movement such as walking or bending
relieving factors
-slight pain relief with rest
-feels most comfortable when lying flat on back
-denies hear or ice
impact of pain of ADL
-pain interferes with ADLs
-slight sleep disturbance
-no exercise since accident
-receiving help from mom and sister
confirmed use of meds
-confirms meds
-increased ibuprofen use for pain
followed up on ibuprofen