We Offer Paper Writing Services on all Disciplines

Make an Order Now and we will be Glad to Help

Order Now



Ask an expert to help you with your homework

We are ready to assist you anytime.

Order Now

Advanced Physical Assessment

Musculoskeletal Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

Return to Assignment (/assignments/313477/)

Documentation / Electronic Health Record

Save your time - order a paper!

Get your paper written from scratch within the tight deadline. Our service is a reliable solution to all your troubles. Place an order on any task and we will take care of it. You won’t have to worry about the quality and deadlines

Order Paper Now

Document: Provider Notes

Student Documentation Model Documentation

Subjective

This is a 28 yo pleasant african american female. She is the primary source of history and offers information freely. she speaks clearly and coherent and maintains contact throughout the exam. She presents to the clinic with c/o back pain for 3 days. Pain is 5/10, takes advil and pain reduces to 2-3/10. Her pain in her lower back and upper buttocks. Gets worse when she is laying down. Is able to perform her normal acitivities. Medication: Proventil, albuterol. advil for pain, PRN Med allergy: PCN: hives and rash Medical history: Diabetes no meds Asthma: on Proventil and albuterol. Controlled asthma with meds No surgical history. No hx of trauma No family history of musculskeletal system disease Family history of HTN and Diabetes

HPI: Ms. Jones presents to the clinic complaining of back pain th 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 not know the weight the box that caused her pain. The pain is in her low back and bilateral buttocks, is a constant aching with stiffness, and does n radiate. The pain is aggravated by sitting (rates a 7/10) and decreased by rest and lying flat on her back (pain of 3-4/10). The pain has not changed over the past three days and she has treat with 2 over the counter ibuprofen tablets every 5-6 hours. Her current pain is a 5/10, but she states that the ibuprofen can decrease her pain to 2-3/10. She denies numbness, tingling, mus weakness, bowel or bladder incontinence. She presents today as pain has continued and is interfering with her activities of daily liv Social History: Ms. Jones’ job is mostly supervisory, although sh does report that she may have to sit or stand for extended period time. She denies lifting at work or school. She states that her pai has limited her activities of daily living. She denies use of tobacc alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Musculoskeletal: Den muscle weakness, pain, joint instability, or swelling. She does sta that she has difficulties with range of motion. She does state tha pain in her lower back has impacted her comfort while sleeping a sitting in class. She denies numbness, tingling, radiation, or bowel/bladder dysfunction. She denies previous musculoskeleta injuries or fractures. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures.

Your Results Lab Pass (/assignment_attempts/6633867/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Document: Provider Notes

 

 

Student Documentation Model Documentation

Objective

HENT: WNL No abnormalities found Upper extremiteis: WNL: no abnormality found: ROM: wnl Spine: reduced ROM for extension and flexion and lateral bending Hips: ROM wnl Lower extremity: Root foot with scar: healed well . Strength tests all wnl for upper and lower extremities.

General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. maintains eye contact throughout interview and examination. Musculoskeletal: Bilateral upper extremities without muscle atrop or joint deformity. Bilateral upper extremities with full range of mo of shoulder, elbow, and wrist. No evidence of swollen joints or sig of infection. Bilateral lower extremities without muscle atrophy or joint deformity, full range of motion of bilateral hips, knees, and ankles. No evidence of swollen joints or signs of infection. Flexio extension, lateral bending, and rotation of the spine with reduced ROM – pain and difficulty. Bilateral upper extremity strength equa and 5/5 in neck, shoulders, elbows, wrists, hands. Bilateral lowe extremity strength equal and 5/5 in hip flexors, knees, and ankles

Assessment

Lower Back Pain Low back muscle strain related to lifting

Plan

Refer to physical therapy Review body mechanics Advil prn as needed, Discuss exercise and weight bearing exercises Return to clinic if symptoms worsen

Provide Ms. Jones with materials detailing stretching techniques the lower back. • Initiate treatment with ibuprofen 600 mg by mo every six to eight hours with food as needed for pain for the next weeks. She may use acetaminophen 500-1000 mg by mouth eve hours for breakthrough pain. • Ms. Jones can also use adjunct therapy of topical heat or ice per comfort TID-QID. • Educate on proper body mechanics and lifting techniques. • Educate on whe seek emergent care including loss of bowel or bladder function, acute changes in sensation of lower extremities, or limitations in movement of lower extremities. • Return to clinic in two weeks fo follow up and evaluation of symptoms.

Comments

If your instructor provides individual feedback on this assignment, it will appear here.

© Shadow Health 2012 – 2020 (800) 860-3241 | Help Desk (https://support.shadowhealth.com/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents

(https://www.shadowhealth.com/patents)

®

 

"Our Prices Start at $11.99. As Our First Client, Use Coupon Code GET15 to claim 15% Discount This Month!!":

Get started

How it works

Place an order

Select the paper type, page limit, discipline, and format, and then set the deadline. Specify your paper instructions and attach the additional materials.

Track the progress

Check the finished parts of the paper and ask for amendments if necessary. Use the online chat for quick communication with the writer

Receive a paper

Release the payment when you are fully satisfied with the work. Leave feedback to share your experience with our writer.

Why our online essay writing service?

All types of paper writing help

Whether you need an essay, research paper, or dissertation, We have you covered. Our writers can create any kind of academic writing. Also, we can rewrite and edit your papers.

24/7 support

If you have questions about our service or need additional details to make a request, our friendly customer support will get your issues resolved.

On time delivery

Punctuality is our second name. Your order will be delivered strictly within the deadline. If you have an urgent order, we can do it! Our writers will need at least three hours to complete it.

Let us cover any of your writing needs!

Academic Paper Writing Service

Our best writers will gladly help you with:

Coursework / Homework

  • Homework Assignment
  • Engineering Assignment
  • Statistics Assignment
  • Biology Assignment
  • Nursing Assignment
  • Chemistry Assignment

Paperwork

  • Essay
  • Term Paper
  • Research Paper
  • Thesis / Dissertation
  • Research Proposal
  • Editing and proofreading

Others

  • Multiple Choice Questions
  • Short Answer Questions
  • Word Problems
  • Programming Assignment
  • Article Writing
  • Mathematics Calculations