Answers Graded A+
chief complaint - ANSWER --reports low relieving factors - ANSWER --slight pain
back pain relief with rest
-describes injury as a "tweak to back" -feels most comfortable when lying flat on back
-denies hear or ice
onset of pain - ANSWER --original injury
occurred 3 days ago impact of pain of ADL - ANSWER --pain
-sudden onset interferes with ADLs
-happed when lifting heavy box -slight sleep disturbance
-no exercise since accident
-receiving help from mom and sister
location of pain - ANSWER --located in low
back and butt
-does not radiate or migrate confirmed use of meds - ANSWER --
-denies neck pain confirms meds
-denies pain between shoulder blades -increased ibuprofen use for pain
-reports pain is same on both sides of back
followed up on ibuprofen - ANSWER --take
frequency and duration of pain - for past 3 days
ANSWER --pain lasted 3 days -last dose ~5 hours ago
-constant pain -takes 2 at a time
-takes every 5-6 hours per instructions
-unsure of dose, not extra strenght
severity of pain - ANSWER --current pain -provides relief for several hours
"pretty bad"
-original injury as 6 or 7/10
-current pain 5/10 confirms allergies - ANSWER -no new
allergies reported
character of pain - ANSWER --pain at the
onset was sharp possible contributing factors in health history -
-aching pain ANSWER --no hx of previous back
-denies burning pain pain/injury
-back is sore to touch -no hx of severe trauma
-pain accompanied by stiffness -denies past surgery
-denies increase in alcohol use since injury
-denies hx of fractures
aggravating factors - ANSWER --feels least -denies heavy lifting at work
comfortable when sitting
-some pain with movement such as walking or
bending impact of pain on income and education -
ANSWER --no missed work due to pain
-no missed school due to pain, but discomfort
1/3