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
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