3/6/25, 11:27
PM
Musculoskeletal Results | Turned In
Advanced Health Assessment - January 2025, 11041.202510
Return to Assignment (/assignments/1128415/)
Your Results Lab Pass (/assignment_attempts/18663790/lab_pass.p
Overvie
Documentation / Electronic Health Record
w
Transcri Document: Provider Notes
pt
Subjective Data
Collection
Objective Data
Collection Education Document: Provider Notes
& Empathy Student Documentation Model Documentation
Documentation
HPI: Ms. Jones presents to the clinic complaining
Video Tutorial of ba pain that began 3 days ago after she
“tweaked it” while lifting a heavy box while
helping a friend move. She sta that lifted
Subjective several boxes before this event without incide
and does not know the weight of the box that
HPI caused h pain. The pain is in her low back and
Ms Jones presents to the clinic with complaints of bilateral buttocks, constant aching with
back pain that started 3 days ago after she stiffness, and does not radiate. Th pain is
'tweaked' her back, while lifting a heavy box. She aggravated by sitting (rates a 7/10) and decreas
does not recall the weight of the box. The pain is in by rest and lying flat on her back (pain of 3-
her lower back and buttocks, and she describes it 4/10). The has not changed over the past three
as a constant aching with stiffness that does not days and she has treated with 2 over the
radiate. it is worsened by sitting (7/10), and counter ibuprofen tablets every hours. Her
decreased by lying on her back (3-4/10). the pain current pain is a 5/10, but she states that th
has remined the same since onset, and is currently ibuprofen can decrease her pain to 2-3/10. She
a 5/10. The pain interferes with activiteis of daily denies numbness, tingling, muscle weakness,
living. She takes OTC Ibuporfen 2 tabs every 5-6 bowel or bladde incontinence. She presents
hrs for the pain, and this reduces it to 2-3/10. She today as the pain has continued and is
reports no numbness muscle weakness, tingling, interfering with her activities of daily li
ow bowel or bladder incontinence.
Social History: Ms. Jones’ job is mostly
SociaL Hx supervisory, although she does report that she
She has a supervisory job, and may have to sit or may have to sit or st for extended periods of
stand for long periods of time. She denies tobacco time. She denies lifting at work school. She
or illicit drug use, but occasionally takes alcohol. states that her pain has limited her activitie
She does not exercise daily living. She denies use of tobacco, alcohol,
and illi drugs. She does not exercise.
ROS
Musculoskeletal; Review of Systems: General: Denies changes in
Reports reduced range of motion in back. Denies weigh fatigue, weakness, fever, chills, and night
muscle weakness, pain, joint pain, swelling. She sweats. • Musculoskeletal: Denies muscle
also denies previous fractures or injuries weakness, pain, joint instability, or swelling. She
Other systems unremarkable. does state that she has difficulties with range of
motion. She does state that the pain in her 1/
lower back has impacted her comfort while 2
PM
Musculoskeletal Results | Turned In
Advanced Health Assessment - January 2025, 11041.202510
Return to Assignment (/assignments/1128415/)
Your Results Lab Pass (/assignment_attempts/18663790/lab_pass.p
Overvie
Documentation / Electronic Health Record
w
Transcri Document: Provider Notes
pt
Subjective Data
Collection
Objective Data
Collection Education Document: Provider Notes
& Empathy Student Documentation Model Documentation
Documentation
HPI: Ms. Jones presents to the clinic complaining
Video Tutorial of ba pain that began 3 days ago after she
“tweaked it” while lifting a heavy box while
helping a friend move. She sta that lifted
Subjective several boxes before this event without incide
and does not know the weight of the box that
HPI caused h pain. The pain is in her low back and
Ms Jones presents to the clinic with complaints of bilateral buttocks, constant aching with
back pain that started 3 days ago after she stiffness, and does not radiate. Th pain is
'tweaked' her back, while lifting a heavy box. She aggravated by sitting (rates a 7/10) and decreas
does not recall the weight of the box. The pain is in by rest and lying flat on her back (pain of 3-
her lower back and buttocks, and she describes it 4/10). The has not changed over the past three
as a constant aching with stiffness that does not days and she has treated with 2 over the
radiate. it is worsened by sitting (7/10), and counter ibuprofen tablets every hours. Her
decreased by lying on her back (3-4/10). the pain current pain is a 5/10, but she states that th
has remined the same since onset, and is currently ibuprofen can decrease her pain to 2-3/10. She
a 5/10. The pain interferes with activiteis of daily denies numbness, tingling, muscle weakness,
living. She takes OTC Ibuporfen 2 tabs every 5-6 bowel or bladde incontinence. She presents
hrs for the pain, and this reduces it to 2-3/10. She today as the pain has continued and is
reports no numbness muscle weakness, tingling, interfering with her activities of daily li
ow bowel or bladder incontinence.
Social History: Ms. Jones’ job is mostly
SociaL Hx supervisory, although she does report that she
She has a supervisory job, and may have to sit or may have to sit or st for extended periods of
stand for long periods of time. She denies tobacco time. She denies lifting at work school. She
or illicit drug use, but occasionally takes alcohol. states that her pain has limited her activitie
She does not exercise daily living. She denies use of tobacco, alcohol,
and illi drugs. She does not exercise.
ROS
Musculoskeletal; Review of Systems: General: Denies changes in
Reports reduced range of motion in back. Denies weigh fatigue, weakness, fever, chills, and night
muscle weakness, pain, joint pain, swelling. She sweats. • Musculoskeletal: Denies muscle
also denies previous fractures or injuries weakness, pain, joint instability, or swelling. She
Other systems unremarkable. does state that she has difficulties with range of
motion. She does state that the pain in her 1/
lower back has impacted her comfort while 2
