Assignment 8.2 Shadow Health Focused Assessment
Mr. Bailey is a 30 yo transgender male with no known PMH, presenting to clinic today
with low back pain. Pt reports pain began after lifting a heavy box at work. Pain is described as
7/10 burning/sharp lower back pain. Pt denies additional symptoms associated with injury. Pt
states aggravating factors are lifting, walking and physical therapy. Mr. Bailey presented to the
hospital the day of the injury. The hospital found no acute injury on MRI and prescribed
ibuprofen and physical therapy. Reports drinking and taking opioids for pain.
I have recommended Mr. Baily to take ibuprofen 800mg for pain every 8 hours as
needed. In addition, education was provided for avoid alcohol and taking medications which are
not prescribed. Recommendations to include continuing physical therapy, ice therapy, and rest
provided. Pt instructed to return if symptoms persist.
This assignment taught me to perform a thorough assessment in diagnosing chronic back
pain. Through reading the American College of Physicians clinical guidelines for noninvasive
treatments for acute, subacute and chronic low back pain, I was able to make appropriate
recommendations based on the assessment information received from my patient. Mr. Bailey
described taking ibuprofen (not as directed) without relief. Based on this subjective information,
I was able to follow the clinical guidelines for treatment of chronic back pain. This assignment
helped me learn how to apply the principles of pain management through going from assessment
to management of a patient presenting with chronic low back pain.
Mr. Bailey is a 30 yo transgender male with no known PMH, presenting to clinic today
with low back pain. Pt reports pain began after lifting a heavy box at work. Pain is described as
7/10 burning/sharp lower back pain. Pt denies additional symptoms associated with injury. Pt
states aggravating factors are lifting, walking and physical therapy. Mr. Bailey presented to the
hospital the day of the injury. The hospital found no acute injury on MRI and prescribed
ibuprofen and physical therapy. Reports drinking and taking opioids for pain.
I have recommended Mr. Baily to take ibuprofen 800mg for pain every 8 hours as
needed. In addition, education was provided for avoid alcohol and taking medications which are
not prescribed. Recommendations to include continuing physical therapy, ice therapy, and rest
provided. Pt instructed to return if symptoms persist.
This assignment taught me to perform a thorough assessment in diagnosing chronic back
pain. Through reading the American College of Physicians clinical guidelines for noninvasive
treatments for acute, subacute and chronic low back pain, I was able to make appropriate
recommendations based on the assessment information received from my patient. Mr. Bailey
described taking ibuprofen (not as directed) without relief. Based on this subjective information,
I was able to follow the clinical guidelines for treatment of chronic back pain. This assignment
helped me learn how to apply the principles of pain management through going from assessment
to management of a patient presenting with chronic low back pain.
