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SH Musculoskeletal Tina Jones 112
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SH Musculoskeletal Tina Jones 112
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SH Musculoskeletal Tina Jones 112chief complaint - ANSWER--reports low back pain
-describes injury as a "tweak to back"
onset of pain - ANSWER--original injury occurred 3 days ago
-sudden onset
-happed when lifting heavy box
location of pain - 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 - ANSWER--pain lasted 3 days
-constant pain
severity of pain - ANSWER--current pain "pretty bad"
-original injury as 6 or 7/10
-current pain 5/10
, character of pain - ANSWER--pain at the onset was sharp
-aching pain
-denies burning pain
-back is sore to touch
-pain accompanied by stiffness
aggravating factors - ANSWER--feels least comfortable when sitting
-some pain with movement such as walking or bending
relieving factors - ANSWER--slight pain relief with rest
-feels most comfortable when lying flat on back
-denies hear or ice
impact of pain of ADL - ANSWER--pain interferes with ADLs
-slight sleep disturbance
-no exercise since accident
-receiving help from mom and sister
confirmed use of meds - ANSWER--confirms meds
-increased ibuprofen use for pain
followed up on ibuprofen - 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
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