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

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Started: Apr 15, 2020 | Total Time: 79 min

Question 04/15/20 4:42 PM MD

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

ShadowHealth
ShadowHealth

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

All Lines (235) Interview Questions (76) Statements (55) Exam Actions (104)

Hey.

May I ask what brings you in today (No matching questions found.)

She went to the clinic today (No matching questions found.)

What brings you into the clinic this morning

Well, I have a lot of pain in my lower back. It really hurts, and it doesn’t seem to be going away. It’s making it kind of hard to get things done, so I decided to come in and have it looked at.

Thanks for understanding.

May I ask when did this pain start (Clarified to When did the pain start?.)

It started three days ago, right when I first tweaked my back. (Clarified to when the pain started.)

Do you have any medical history of muscular skeletal system

Other than my back? I have diabetes and asthma.

What are you taking for diabetes

I don’t take medicine for it anymore.

What are you taking for your asthmahttps://aspen.shadowhealth.com/assignments/313477/https://aspen.shadowhealth.com/assignment_attempts/6633867/lab_pass.pdf

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I have a Flovent daily inhaler and a Proventil rescue inhaler.

How often are you using your proventil

I haven’t used my rescue inhaler in months — not since I started the daily Flovent one.

That makes sense.

Can I ask where is the pain located

It hurts in my lower back and even, like, the top of my butt.

How long does it pain last

It’s pretty constant.

What does it feel like

It’s like. . . an ache.

Is there something that makes it worse

Well, I’ve been taking Advil for it. Otherwise the only thing that really helps is lying flat on my back.

How often are you taking Advil

I’ve been taking them every five or six hours, like it says on the bottle.

How many days have you been taking it (Clarified to For how many days have you been on pain pills?.)

I’ve been taking the Advil about three days, maybe a little less–since the night after I hurt myself. (Clarified to how many days I have been taking pain pills.)

Is there something that makes your back pain worse

It definitely feels worst when I’m sitting up. Moving around can make it hurt more, too.

Is there anything related with the back pain

Taking Advil has been helping a little. . . and it feels better when I lie flat on my back.

Does your back pain radiates anywhere

No, it isn’t spreading.

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Are you able to walk okay

I can walk, but it does hurt a little.

Do you need to use a walker

I can walk, but it does hurt a little.

From 1 to 10 what is your pain scale (Clarified to Can you rate your current back pain level on a scale of 0 to 10?.)

Without medication, it depends on what position I’m in, but I’d say probably it averages about 5 out of 10. (Clarified to to rate my back pain on a scale.)

When you take the medication what is your pain scale

When the Advil’s just kicking in the pain goes down to a 2 or 3 out of 10, I’d say.

Are you having any joint pain

No, my joints feel fine.

Are you able to stand up

It actually feels a little better when I’m standing than when I’m sitting.

Have you had history of muscle soreness before

Sore muscles aren’t usually a problem for me, but I think it’s this muscle in my back that is causing me so much pain. [AUDIO COMING SOON]

May I ask what do you do at work

Well, since being promoted to supervisor, I’ve been in charge of scheduling other employees, taking inventory, and placing orders for supplies. I’m still on the floor a lot though, dealing with customers and that sort of thing. It’s mostly a lot of standing and walking around.

Have you had any muscle injury

Well, I guess it’s the muscle in my back that’s hurting.

Has this ever happened before (No matching questions found.)

Did you have this problem before

No, nothing like this has ever happened to me. . . my back is usually totally fine.

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Do you have a family history of back pain

No, I don’t think so.

Do you have any family medical history

My mom has some issues, and I think some of my grandparents did, too.

What is your mother’s medical history

Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.

What is your medical history of your grandparents

Well. . . I have diabetes. And asthma.

Are you allergic to any medication

Yeah, I’m allergic to penicillin.

What happens if penicillin

I don’t remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that.

Are you taking any other medication

I’ve been taking Advil for my back, and I also have my inhalers.

Are you taking any illicit drugs

No.

Have you ever had ligament sprain

No.

Have you found any history of muscular skeletal system (No matching questions found.)

do you have family history of skeletal muscular problems

Not that I know of.

Able to do your daily activities (Clarified to Are you able to perform all of your usual daily activities?.)

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Well, I came in because the pain wasn’t going away, and I can’t really sit or move a lot. But I can do everything I need to, it’s just much harder. (Clarified to if I am able to perform daily activities.)

Do you have muscle weakness

No, I wouldn’t say I feel weak.

Do you have problems with your pelvic area

I’ve always been a little on the heavy side, but I think that’s just how my body is. I don’t struggle with it.

Do you exercise daily

I don’t usually exercise much, and I definitely haven’t since this happened.

do you have Arthritis

No, I don’t, fortunately.

Hip pain radiate anywhere

No, it isn’t spreading.

Have you had any trauma

No, nothing like this has ever happened to me. . . my back is usually totally fine.

Do you have family history of osteoporosis

No.

I appreciate you telling me that.

OK, I understand.

Do you have any muscular skeletal problems

Well, I guess it’s the muscle in my back that’s hurting.

Is that all (No matching questions found.)

Thanks for telling me.

Sure, I think I understand what you mean.

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Alright, thanks for letting me know.

That makes sense.

Does your hands feel swollen (Clarified to Are your hands numb?.)

I haven’t been numb anywhere. (Clarified to if my hands are numb.)

Does your arms feel cold

No, it’s just my back that hurts.

Hurt to move your arms

No, it’s just my back that hurts.

Do you get carpal tunnel (No matching questions found.)

Do you have carpal tunnel (No matching questions found.)

does your hands swell (Clarified to Do your hands feel cold?.)

No. (Clarified to if my hands are cold.)

do you have \Carpal tunnel (No matching questions found.)

do you have Carpal tunnel (No matching questions found.)

Do you have problems with your hands

Nope.

Thanks for telling me.

Thanks for saying that.

Can you point to the pain

The pain’s just in my back and the top of my butt.

Have you had any surgery

Nope. No surgeries… I’ve been lucky.

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OK, I understand.

Does your thighs hurt (No matching questions found.)

do you have pain in your thighs (No matching questions found.)

do you have pain on your thigh

Nope.

Sure, I think I understand what you mean.

Alright, thanks for letting me know.

Do they get swollen (No matching questions found.)

Do your ankles get swollen (Clarified to Are your ankles giving you trouble?.)

My ankles are fine. [AUDIO COMING SOON] (Clarified to if I have ankle problems.)

I appreciate you saying that.

Sure, I think I understand what you mean.

That makes sense.

OK, I understand.

Do you feel any pain

Yes! My back feels really bad right now.

Do you have neck pain

No, there’s nothing going on with my neck. . . it’s just my back that’s bothering me.

Thanks for telling me.

Alright, thanks for letting me know.

Sure, I think I understand what you mean.

Do you have any pain

Yes! My back feels really bad right now.

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Thanks for telling me.

Alright, thanks for letting me know.

That makes sense.

OK, I understand.

Alright, thanks for letting me know.

Does your left side hurt

Nope.

Thanks for telling me.

Thanks.

OK, I understand.

That makes sense.

Sure, I think I understand what you mean.

OK, I understand.

I appreciate you telling me that.

Thanks for telling me.

Alright, thanks for letting me know.

Rotate your left foot away from you so you can see the bottom outer edge of the foot (No matching questions found.)

Sure, I think I understand what you mean.

That makes sense.

OK, I understand.

Thanks for telling me.

Sure, I think I understand what you mean.

Alright, thanks for letting me know.

That makes sense.

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OK, I understand.

Alright, thanks for letting me know.

Sure, I think I understand what you mean.

Thanks for telling me.

That makes sense.

Sure, I think I understand what you mean.

Thanks for understanding.

OK, I understand.

Alright, thanks for letting me know.

That makes sense.

Thanks for telling me.

OK, I understand.

That makes sense.

Thanks for telling me.

What is your diet like

It’s pretty good, I think. I’m not a huge health nut or anything.

Have you had a change of weight

No, I don’t really think so.

Have you gained weight recently (Clarified to Have you gained or lost weight recently?.)

No, I don’t really think so. (Clarified to if I have gained or lost weight recently.)

Are you having trouble eating (Clarified to Do you have problems eating food?.)

No, I really try not to worry too much about what I eat. (Clarified to if I have problems with eating.)

Sciatica pain (No matching questions found.)

Question 04/15/20 5:59 PM MDdo you have sciatica pain

I don’t have that. Or, no one’s told me I do. [AUDIO COMING SOON]

Comments

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

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