NURS 653 Tina Jones Musculoskeletal Transcript Updated, Exams of Nursing

Download NURS 653 Tina Jones Musculoskeletal Transcript Updated and more Exams Nursing in PDF only on Docsity! Transcript AllLines(185)Interview Questions(84)Statements(8)Exam Actions(93) hello ms. jones, my name is and I am a family nurse practitioner student with Houston Baptist University and I will be interviewing and examining you today if that is alright with you Hey. what brings you in today Greet 11/15/21 10:24 PM CST Question 11/15/21 10:24 PM CST 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. Started:No 15,2021| TotalTime:240min i am sorry to hear that you are having this lower back pain. I hope we can get to the root cause of your pain today and fix this problem and alleviate your pain Thanks for understanding. do you remember what caused your pain? (Clarified to What do you think brought on the pain?.) Empathize 11/15/21 10:25 PM CST Question 11/20/21 11:39 PM CST I think it's hurting from when I tweaked it while I was lifting a box. (Clarified to what I think caused my pain.) when did you hurt yourself Question 11/20/21 11:40 PM CST Question 11/20/21 11:58 PM CST I'm not sure of the number...It's just regular Advil, not extra strength or anything. (Clarified to what dosage of Advil I take.) how much advil did you take Question 11/20/21 11:58 PM CST I've been taking them every five or six hours, like it says on the bottle. how many ibuprofen pills did you take Question 11/20/21 11:59 PM CST I take two pills. are you taking any other medications Question 11/21/21 12:00 AM CST I've been taking Advil for my back, and I also have my inhalers. Thank you for telling me the medications you use. Sometimes some medications can interact and harmful side CST Can you describe how you were moving boxes Question 11/21/21 3:41 AM CST Um. . . I don't know. I was, like, bending over and picking them up? Maybe I should have used my knees more. . . you should bend at the knees and not at your waist or back. Spread your feet apart to give yourself a wide base to support yourself.Tighten your stomach muscles and lift slowly. Always hold the object as close as possible to you. This technique helps prevent injury. Educate 11/21/21 3:48 AM CST 3:55 AM CST Sure, I think I understand what you mean. how many days have you been taking the advil Question 11/21/21 3:50 AM CST I've been taking the Advil about three days, maybe a little less--since the night after I hurt myself. what makes worse 4:55 AM CST Question 11/21/21 No, it isn't spreading. have you applied ice or heat Question 11/21/21 4:09 AM CST No. I didn't try that. [AUDIO COMING SOON] do you wear a back brace (No matching questions found.) Question 11/21/21 4:11 AM CST how do you feel in the morning (No matching questions found.) Question 11/21/21 4:23 AM CST do you wake up feeling stiff (Clarified to Do you wake up feeling refreshed?.) Question 11/21/21 4:24 AM CST Yeah, I think so. (Clarified to if I wake up feeling rested.) is the pain constant? Question 11/21/21 4:26 AM CST It's constant, yeah. Does it stop you from performing your activities of daily living? (No matching questions found.) Question 11/21/21 4:29 AM CST Do you work? Question 11/21/21 4:29 AM CST Yes, of course. I'm a supervisor at Mid- American Copy & Ship. Does the pain stop you from working? Question 11/21/21 4:29 AM CST CST Thanks for telling me. have you been to work lately Question 11/21/21 4:32 AM CST I haven't missed any work. . . work isn't so bad, since I'm mostly standing up for it. Do you exercise of ten (Clarified to Do you exercise?.) CST Question 11/21/21 4:59 AM I don't usually exercise much, and I definitely haven't since this happened. (Clarified to if I exercise.) can you remember anything else about the pain when it happened (No matching questions found.) Question 11/21/21 5:00 AM CST can you remember anything about the pain when it happened (No matching questions found.) Question 11/21/21 5:01 AM CST can you describe the pain at the time of the injury Question 11/21/21 5:02 AM CST 5:08 AM CST I'm really just worried about my back right now. i know you are in pain right now, but it is important that I know your full medical history to help me diagnose and prescribe the proper treatment tailored to you. Alright, thanks for letting me know. what do you use inhalers for Educate 11/21/21 5:07 AM CST Question 5:08 AM CST 11/21/21 5:09 AM CST Well, this one is a maintenance inhaler, so I'm supposed to use it every day. And I do. do you have a history of asthma Question 11/21/21 5:08 AM CST Yeah, though it's not as bad as it used to be when I was a kid. have you ever hospitalized 5:10 AM CST Question 11/21/21 5:10 AM CST Yeah, I'm allergic to penicillin. do you have any latex allergies Question 11/21/21 5:10 AM CST Nope. do you have food allergies 5:10 AM CST Question 11/21/21 5:13 AM CST No more than once or twice a week, sometimes less. do you smoke cigarettes Question 11/21/21 5:13 AM CST No. I think it's gross. do you vape 5:14 AM CST Question 11/21/21 5:15 AM CST No way. do you smoke marijuana Question 11/21/21 5:13 AM CST Um, yeah, I've done that before. In high school, and after high school... I definitely don't anymore, though. do you take illicit drugs 5:18 AM CST Question 11/21/21 5:19 AM CST I'm really just worried about my back right now. can you tell me the name and dose of your inhalers Question 11/21/21 5:18 AM CST I'm not sure of the exact dose off the top of my head, but I use it twice daily. [AUDIO COMING SOON] what is the name your inhaler 5:20 AM CST Question 11/21/21 CST My mom has some issues, and I think some of my grandparents did, too. what health issues did your mom have Question 11/21/21 5:20 AM CST Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though. Does anyone in your family have musculoskeletal issues CST Question 11/21/21 5:24 AM CST No, I don't think so. does anyone in your family have back problems Question 11/21/21 5:24 AM CST No, I don't think so. does anyone in your family have osteoporosis 5:28 AM CST Question 11/21/21 5:29 AM CST He had high blood pressure and cholesterol, and diabetes too...the same kind as me. Are your parents still alive Question 11/21/21 5:28 AM CST No. Dad passed away last year. In a car accident. i am sorry to that. 5:30 AM CST Empathize 11/21/21 He's a healthy guy. Kinda big like me. what is your sister's medical history (No matching questions found.) Question 11/21/21 5:32 AM CST what is your sister's past medical history Question 11/21/21 5:33 AM CST Well. . . I have diabetes. And asthma. does your sister have any medical problems Question 11/21/21 5:33 AM CST She's pretty healthy. She has asthma but almost never has attacks. has the pain caused you to miss work Question 11/21/21 5:34 AM CST I haven't missed any work. . . work isn't so bad, since I'm mostly standing up for it. have you had any headaches Question 11/21/21 5:36 AM CST 5:37 AM CST Nothing's been wrong with my head since I hurt my back. I do get headaches sometimes, but that's just when I read or I'm studying. have you been fatigued Question 11/21/21 5:36 AM CST I haven't been feeling any more tired than usual. have you ever broken any 5:42 AM CST Question 11/21/21 CST I haven't had a fever, no. have you ever injured your back before Question 11/21/21 3:54 PM CST No, nothing like this has ever happened to me. . . my back is usually totally fine. have you ever been in a car accident Question 11/21/21 CST 3:54 PM 3:58 PM CST Sometimes I'll have to lift something, but if it's heavy I never have to do it alone, and I don't have to carry anything very far. (Clarified to if my work involves heavy lifting.) have you had any weakness Question 11/21/21 3:58 PM CST No, I wouldn't say I feel weak. have you ever a muscle 3:59 PM CST Question 11/21/21 3:60 PM CST Well, I guess it's the muscle in my back that's hurting. do you have any numbness or tingling Question 11/21/21 3:59 PM CST No, I'm not numb or tingling. have you had dizziness 4:01 PM CST Question 11/21/21 CST No, I'm a creature of habit. I eat the same foods all the time. have you noticed any changes in your bowel or bladder patterns? Question 11/21/21 4:01 PM CST Um. . . everything's been normal. Do you have joint pain or CST Question 11/21/21 4:03 PM No, I haven't noticed anything like that. (Clarified to if I have ever had swollen joints.) have you had any chills or night sweats Question 11/21/21 4:09 PM CST I don't get sweaty, but sometimes I wake up hot and have to kick off my sheets. Inspected front of neck Exam Action 11/21/21 4:14 PM CST Inspected right side of neck Exam Action 11/21/21 4:16 PM CST Inspected back of neck Exam Action 11/21/21 4:16 PM CST Inspected left side of neck Exam Action 11/21/21 4:16 PM CST Inspected back of neck Exam Action 11/21/21 4:17 PM CST Inspected shoulders from the front Exam Action 11/21/21 4:17 PM CST Inspected right shoulder Exam Action 11/21/21 4:18 PM CST 4:19 PM CST Inspected upper back Exam Action 11/21/21 4:18 PM CST Inspected left shoulder Exam Action 11/21/21 4:18 PM CST Inspected shoulders from the front Exam Action 11/21/21 4:19 PM CST Inspected right shoulder Exam Action 11/21/21 4:19 PM CST Inspected right arm Exam Action 11/21/21 4:19 PM CST Inspected left arm Exam Action 11/21/21 Inspected right side of hips Exam Action 11/21/21 4:23 PM CST Inspected both hands Exam Action 11/21/21 4:22 PM CST Inspected right hand Exam Action 11/21/21 4:22 PM CST Inspected both hands Exam Action 11/21/21 4:22 PM CST Inspected left hand Exam Action 11/21/21 4:22 PM CST Inspected front of hips Exam Action 11/21/21 4:23 PM CST 4:25 PM CST Inspected back of hips Exam Action 11/21/21 4:23 PM CST Inspected left side of hips Exam Action 11/21/21 4:23 PM CST Inspected front of thighs Exam Action 11/21/21 4:24 PM CST Inspected right thigh Exam Action 11/21/21 4:24 PM CST Inspected back of thighs Exam Action 11/21/21 4:25 PM CST Inspected left thigh Exam Action 11/21/21 4:25 PM CST Inspected front of thighs Exam Action 11/21/21 4:25 PM CST Inspected front of knees Exam Action 11/21/21 4:25 PM CST Inspected right knee Exam Action 11/21/21 4:25 PM CST Inspected back of knees Exam Action 11/21/21 4:25 PM CST Inspected left knee Exam Action 11/21/21 4:25 PM CST Inspected front of knees Exam Action 11/21/21 4:31 PM CST Inspected both ankles Exam Action 11/21/21 4:29 PM CST Inspected left ankle Exam Action 11/21/21 4:29 PM CST Inspected both ankles Exam Action 11/21/21 4:29 PM CST Inspected right ankle Exam Action 11/21/21 4:29 PM CST Inspected soles of feet: Right: No visible abnormal findings, new skin tissue from healed wound, expected curvature. Left: No visible abnormal findings, expected curvature Exam Action 11/21/21 4:30 PM CST Inspected right foot 4:31 PM CST Exam Action 11/21/21 4:35 PM CST Inspected soles of feet: Right: No visible abnormal findings, new skin tissue from healed wound, expected curvature. Left: No visible abnormal findings, expected curvature Inspected left foot Exam Action 11/21/21 4:31 PM CST Exam Action 11/21/21 4:31 PM CST Inspected soles of feet: Right: No visible abnormal findings, new skin tissue from healed wound, expected curvature. Left: No visible abnormal findings, expected curvature Inspected left foot Exam Action 11/21/21 4:31 PM CST Exam Action 11/21/21 4:31 PM CST Inspected top of feet Exam Action 11/21/21 4:31 PM CST Tested ROM neck - flexion: Expected 4:48 PM CST Tested ROM of elbows - flexion and extension: Expected Exam Action 11/21/21 4:45 PM CST Tested ROM of elbows - supination and pronation: Expected Exam Action 11/21/21 4:45 PM CST Tested ROM of wrists - flexion: Expected Exam Action 11/21/21 4:45 PM CST Tested ROM of wrists - extension: Expected Exam Action 11/21/21 4:46 PM CST Tested ROM of wrists - ulnar and radial deviation: Expected Exam Action 11/21/21 4:46 PM CST Tested spinal ROM - extension: Reduced 4:48 PM CST Exam Action 11/21/21 4:52 PM CST Tested spinal ROM - flexion: Reduced Exam Action 11/21/21 4:49 PM CST Tested spinal ROM - lateral bending: Reduced Exam Action 11/21/21 4:50 PM CST Tested spinal ROM - rotation to the right: Reduced Exam Action 11/21/21 4:50 PM CST Tested spinal ROM - rotation to the left: Reduced Exam Action 11/21/21 4:50 PM CST Tested ROM of hips - flexion: Expected Exam Action 11/21/21 4:52 PM CST Tested ROM of hips - extension: Expected 4:58 PM CST Tested neck strength - head turned to the right: 5/5 Exam Action 11/21/21 4:56 PM CST Tested neck strength - head turned to the left: 5/5 Exam Action 11/21/21 4:56 PM CST Tested neck strength - head tilted to the right: 5/5 Exam Action 11/21/21 4:56 PM CST Tested neck strength - head tilted to the left: 5/5 Exam Action 11/21/21 4:57 PM CST Tested neck strength - head down: 5/5 Exam Action 11/21/21 4:57 PM CST Tested right and left shoulder strength: 5/5 4:58 PM CST Exam Action 11/21/21 5:01 PM CST Tested elbow strength during flexion: 5/5 Exam Action 11/21/21 4:58 PM CST Tested elbow strength during extension: 5/5 Exam Action 11/21/21 4:59 PM CST Tested wrist strength during extension - up: 5/5 Exam Action 11/21/21 4:59 PM CST Tested wrist strength during extension - down: 5/5 Exam Action 11/21/21 5:00 PM CST Tested right and left hand strength with grip test: 5/5 Exam Action 11/21/21 5:00 PM CST Tested right and left hip strength: 5/5