NURS 8020C MUSCULOSKELETAL ASSESSMENT UC NURS 8020C
MUSCULOSKELETAL SYSTEM ASSESSMENT
Pt. Initials: MR Gender: Male Age: 28
S:
CC: “My lower back hurts”
HPI: Patient is a 28-year-old male c/o of lower back pain. Patient states pain was aggravated last week when he was cutting down trees...
MUSCULOSKELETAL SYSTEM
Pt. Initials: MR
Gender: Male
Age: 28
S:
CC: “My lower back hurts”
HPI: Patient is a 28-year-old male c/o of lower back pain. Patient states
pain was aggravated last week when he was cutting down trees on his
mother’s property. Patient does not recall a specific event that may
have caused the pain, just that the next day he woke up with
generalized lower back pain. Patient has not taken any pain medication
OTC or prescription for the pain, rates back pain 5/10. Patient says pain
is relieved with hot pack application to about 2/10. Patient denies a
decrease in lower back movement, trauma to area, or
numbness/tingling. Patient states pain is aggravated with movement,
lifting and as the day progresses. Lying down and applying heat easily
relieve pain.
PMH: Patient has a past medical history of chicken pox, and tonsillitis
and underwent a tonsillectomy in 2015. Patient currently does not take
any prescription medications, over the counter drugs, vitamins, or
supplements. Patient has no known allergies. Patient denies recent use
of NSAIDs.
FH: Patient’s father has a history of heart disease, high blood pressure,
and high cholesterol. Patient’s mother has a history of hypothyroidism
and gestational diabetes. Patient denies any family history of
osteoporosis, gout, Paget’s disease, Dupuytren’s contracture, SLE,
Marfan’s syndrome or scoliosis.
SH: Patient is a nonsmoker, nondrug user, and consumes 1-2 beers per
week. Patient participates in a regular exercise regimen 3-4 days per
week. Patient is married and is sexually active. Patient denies changes
in sleep habits or diet.
ROS:
General: Pt denies any recent weight changes, weakness,
fatigue or
fevers.
Skin, hair, nails: Pt denies any instances of rash, lumps, sores,
itching,
dryness, or color changes. Pt denies any changes to his hair or
nails
Eyes: Pt wears corrective lenses daily. Pt last eye exam was in
April 2015.
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