NR 509 Week 3 Shadow Health Assessment Musculoskeletal Physical Assessment Assignment
NR 509 Week 3 Shadow Health Assessment Musculoskeletal Physical Assessment Assignment
NR 509 Week 3 Shadow Health Assessment Musculoskeletal (Spring 2018)
Subjective:
HPI: Ms. Jones presents to the clinic complaining of back pain that began 3 days ago after she “tweaked it” while lifting a heavy box while helping a friend move. She states that lifted several boxes before this event without incident and does……………………………… She presents today as the pain has continued and is interfering with her activities of daily living.
Social History: Ms. Jones’ job is mostly supervisory, although she does report that she may have to sit or stand for extended periods of time……………. use of tobacco, alcohol, and illicit drugs. She does not exercise.
ROS: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. •
Musculoskeletal: Denies muscle weakness, pain, joint instability, or swelling. She does state that she has difficulties with range of motion…… lower back has impacted her comfort while sleeping and sitting in class…….. numbness, tingling, radiation, or bowel/bladder dysfunction. She denies previous musculoskeletal injuries or fractures. •
Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures.Overview
Subjective:
HPI: Ms. Jones presents to the clinic complaining of back pain that began 3 days ago after she “tweaked it” while lifting a heavy box while helping a friend move. She states that lifted several boxes before this event without incident and does……………………………… She presents today as the pain has continued and is interfering with her activities of daily living.
Social History: Ms. Jones’ job is mostly supervisory, although she does report that she may have to sit or stand for extended periods of time……………. use of tobacco, alcohol, and illicit drugs. She does not exercise.
ROS: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. •
Musculoskeletal: Denies muscle weakness, pain, joint instability, or swelling. She does state that she has difficulties with range of motion…… lower back has impacted her comfort while sleeping and sitting in class…….. numbness, tingling, radiation, or bowel/bladder dysfunction. She denies previous musculoskeletal injuries or fractures. •
Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures.
Objective:
ROS: General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination.
Musculoskeletal: Bilateral upper extremities without muscle atrophy or joint deformity. Bilateral upper extremities with full range of motion of shoulder, elbow, and wrist……………….. upper extremity strength equal and 5/5 in neck, shoulders, elbows, wrists, hands. Bilateral lower extremity strength equal and 5/5 in hip flexors, knees, and ankles.
ASSESSMENT: Low back muscle strain related to lifting