Terms in this set (22)

Original
chief complaint
-reports low back pain
-describes injury as a “tweak to back”

onset of pain
-original injury occurred 3 days ago
-sudden onset
-happed when lifting heavy box

location of pain
-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
-pain lasted 3 days
-constant pain

severity of pain
-current pain “pretty bad”
-original injury as 6 or 7/10
-current pain 5/10

character of pain
-pain at the onset was sharp
-aching pain
-denies burning pain
-back is sore to touch
-pain accompanied by stiffness

aggravating factors
-feels least comfortable when sitting
-some pain with movement such as walking or bending

relieving factors
-slight pain relief with rest
-feels most comfortable when lying flat on back
-denies hear or ice

impact of pain of ADL
-pain interferes with ADLs
-slight sleep disturbance
-no exercise since accident
-receiving help from mom and sister

confirmed use of meds
-confirms meds
-increased ibuprofen use for pain

followed up on ibuprofen
-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 strength
-provides relief for several hours

confirms allergies
no new allergies reported

possible contributing factors in health history
-no hx of previous back pain/injury
-no hx of severe trauma
-denies past surgery
-denies increase in alcohol use since injury
-denies hx of fractures
-denies heavy lifting at work

impact of pain on income and education
-no missed work due to pain
-no missed school due to pain, but discomfort sitting in class

general symptoms
-denies fever, chills, night sweats, NV
-low energy level

ROS for MSK system
-denies muscle weakness
-denies joint pain, swelling, redness, stiffness

ROS for neuro system
-denies headache r/t injury
-denies numbness, tingling, dizziness, light-headedness, disequilibrium
-denies changes to bowel or bladder function

family history
-denies hx of general MSK problems
-denies osteoporosis
-denies arthritis
-denies bone cancer/disease
-denies degenerative muscle disease

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 not know the weight of the box that caused her pain. The pain is in her low back and bilateral buttocks, is a constant aching with stiffness, and does not 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 treated 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, muscle weakness, bowel or bladder incontinence. 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. She denies lifting at work or school. She states that her pain has limited her activities of daily living. She denies use of tobacco, alcohol, and illicit drugs. She does not exercise. Review of Systems: 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. She does state that the pain in her lower back has impacted her comfort while sleeping and sitting in class. She denies 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
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. No evidence of swollen joints or signs 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. Flexion, extension, lateral bending, and rotation of the spine with reduced ROM – pain and difficulty. Bilateral 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
plan
Provide Ms. Jones with materials detailing stretching techniques for the lower back. • Initiate treatment with ibuprofen 600 mg by mouth every six to eight hours with food as needed for pain for the next two weeks. She may use acetaminophen 500-1000 mg by mouth every 8 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 when to 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 for follow up and evaluation of symptoms.