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Questions and Answers
What is the chief complaint reported by Ms. Jones?
Reports low back pain and describes injury as a 'tweak to back'.
The onset of pain for Ms. Jones occurred ___ days ago.
3
Describe the location of Ms. Jones's pain.
Located in low back and butt, does not radiate or migrate.
How long has Ms. Jones been experiencing pain?
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What is the severity of Ms. Jones's original injury on a scale of 1 to 10?
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Ms. Jones denied any burning pain.
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What factors aggravate Ms. Jones's pain?
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What relief measures are effective for Ms. Jones's pain?
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How has the pain impacted Ms. Jones’s activities of daily living (ADLs)?
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What medication has Ms. Jones confirmed using for pain relief?
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How long has Ms. Jones been taking ibuprofen?
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Ms. Jones reports a history of previous back pain or injury.
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Has Ms. Jones missed any work or school due to her pain?
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What are the general symptoms reported by Ms. Jones?
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What is Ms. Jones's assessment?
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What is included in the plan for Ms. Jones's treatment?
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Study Notes
Chief Complaint
- Reports low back pain, describing the injury as a "tweak to the back."
Onset of Pain
- Original injury occurred 3 days ago with sudden onset during heavy lifting.
Location of Pain
- Pain localized in the low back and buttocks; does not radiate.
- Denies neck pain, pain between shoulder blades, or unilateral pain.
Frequency and Duration of Pain
- Pain has persisted for 3 days and is constant.
Severity of Pain
- Original pain rated as 6 or 7/10; current pain at 5/10.
Character of Pain
- Initial pain described as sharp, followed by an aching sensation.
- Back is sore to the touch and accompanied by stiffness; denies burning pain.
Aggravating Factors
- Pain worsens when sitting and with movements like walking or bending.
Relieving Factors
- Slight pain relief experienced with rest; feels most comfortable lying flat on the back.
Impact of Pain on Activities of Daily Living (ADLs)
- Pain interferes with daily activities; slight sleep disturbance reported.
- No exercise since the incident; receiving assistance from family members.
Confirmed Medication Use
- Increased use of ibuprofen confirmed for pain management.
Follow-up on Ibuprofen Use
- Taken for the past 3 days, with the last dose approximately 5 hours ago.
- Takes 2 tablets every 5-6 hours, providing relief for several hours.
Allergy History
- No new allergies reported.
Possible Contributing Factors in Health History
- No history of previous back pain, severe trauma, or surgeries.
- Denies increased alcohol use, fractures, or heavy lifting at work.
Impact of Pain on Income and Education
- No missed work or school due to pain, but feels discomfort when sitting.
General Symptoms
- Denies fever, chills, night sweats, nausea/vomiting.
- Reports low energy levels.
Review of Systems (ROS) for Musculoskeletal System
- Denies muscle weakness, joint pain, swelling, redness, or stiffness.
Review of Systems (ROS) for Neurological System
- Denies headaches related to injury and symptoms like numbness, dizziness, or changes in bowel/bladder function.
Family History
- Denies family history of musculoskeletal problems, osteoporosis, or degenerative muscle diseases.
Subjective Summary
- Presents with low back pain starting 3 days ago after lifting a heavy box. Pain is constant, aching, and impacts ADLs. Reports treatment with ibuprofen.
Objective Findings
- Patient is a pleasant, obese 28-year-old African American woman in no acute distress.
- Full range of motion in upper and lower extremities; reduced ROM in spine with pain. Strength is equal bilaterally.
Assessment
- Diagnosed with low back muscle strain related to lifting.
Plan
- Provide stretching materials for lower back.
- Initiate ibuprofen treatment (600 mg every 6-8 hours with food) for two weeks; may also use acetaminophen for breakthrough pain.
- Advise on topical heat or ice therapy and educate on proper body mechanics for lifting.
- Clarify when to seek emergent care.
- Schedule follow-up in two weeks to evaluate symptoms.
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Description
Test your knowledge with these flashcards focusing on the musculoskeletal system as presented by Tina Jones. Each card covers key terms and definitions related to a case involving low back pain and injury assessment. Perfect for students in health care and related fields.
