Musculoskeletal Physical Assessment Assignment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-October-2018
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Your Results
Subjective Data Collection: 17 of 17 (100.0%)
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Category Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
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A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case.
Chief Complaint
Established chief complaint Reports low back pain
Describes injury as a "tweak" to her back
History of Present Illness
Asked about onset of pain Reports original injury occurred 3 days ago
Onset was sudden
Reports injury happened when lifting a heavy box
Asked about location of pain Reports pain located in low back and buttocks
Reports pain does not radiate or migrate
Denies neck pain
Denies pain between the shoulder blades
Reports pain is the same on both sides of her back
Asked about frequency and duration of pain Reports pain has lasted three days
Reports pain is constant
Asked about severity of pain Describes current pain as "pretty bad" Rates pain of original injury as 6 or 7/10 Reports current pain rating of 5/10
Asked about character of pain Reports pain at the onset as sharp Describes pain as aching Denies burning pain
Reports back is sore to the touch Reports pain accompanied by stiffness
Asked about aggravating factors Reports feeling least comfortable when sitting
Reports some pain with movement such as bending or walking
Asked about relieving factors Reports slight pain relief with rest
Reports feeling most comfortable when lying flat on back Denies use of heating pad or ice
Asked about impact of pain on activities of daily living Confirms pain is interfering with activities of daily living
Reports slight sleep disturbance due to the pain Reports no exercise since accident
Reports no missed work due to pain
Reports no missed school due to pain, but discomfort sitting in class
Reports receiving help with daily tasks from mother and sister
Medical History
Confirmed use of medications Confirms medications
Reports increased ibuprofen use for pain
Followed up on ibuprofen use Has taken ibuprofen for the past 3 days
Last dose of ibuprofen was about 5 hours ago Reports taking two Ibuprofens at a time
Takes ibuprofen every 5-6 hours as per instructions Unsure of dose, describes it as "not extra strength" Ibuprofen provides relief for several hours
Confirmed allergies Confirms allergies (no new allergies reported)
Asked about possible contributing factors in health history
Reports no history of previous back pain or injury Denies history of severe trauma such as car accident or
occupational injury
Denies past surgery
Denies increase in alcohol use since injury Denies history of fractures
Denies heavy lifting at work
Review of Systems
Asked about general symptoms Denies fever Denies chills Denies night sweats
Denies nausea or vomiting Reports low energy level
Asked review of systems for musculoskeletal Denies muscle weakness
Denies joint pain
Denies joint swelling or redness Denies joint stiffness
Asked review of systems for neurological Denies headache related to injury
Denies tingling or numbness in any body part Denies changes to bowel or bladder function
Denies dizziness, light-headedness, and disequilibrium
Family History
Asked about relevant family history Denies family history of general musculoskeletal problems
Denies family history of osteoporosis Denies family history of any form of arthritis
Denies family history of bone cancer or disease Denies family history of degenerative muscle disease [Show Less]