NUR 634 Topic 8 Shadow Health Assignment; Musculoskeletal (MSK)
- $25.00
Chief complaint
“Pain in my lower back” History of Presenting Illness
Tina Jones is 28 y/o African American female with a history of diabetes and asthma presenting to the clinic complaining of a lower back pain making it difficult to perform her activities of daily living. The pain started three days ago after she “tweaked” it lifting a box. She has been medicating herself with two over the counter Advil every 5-6 hours which does decrease her pain. Lying flat on her back also seems to decrease her pain. She notices her pain is worse when sitting up and moving around. She describes the pain as a constant ache that does not radiate and rates her current pain a 5/10. Although she is in significant pain, she has not missed a day of work. She denies numbness, tingling, weakness, and bladder incontinence.
Medical History
Asthma: Diagnosed in 1996. Treated with a daily inhaler and rescue inhaler.
Diabetes: Diagnosed in 2018. Treated by watching what she eats and avoiding sugar. Does not perform frequent BG checks.
Hospitalizations
Multiple hospitalizations for asthma as a child. Last hospitalization was when she was 16 y/o in 2010.
Surgical History No surgical history Family History
Mother: 50y/o. History of Hypertension and high cholesterol
Father: Passed away last year at 58 y/o due to a MVA. History of Hypertension, high cholesterol, and diabetes
Paternal Grandfather: Passed away in his 60’s from colon cancer. History of diabetes. Paternal Grandmother: 82 y/o. History of Hypertension and high cholesterol
Maternal Grandmother: Passed away at 73y/o from a stroke. History of Hypertension and high cholesterol
Maternal Grandfather: Passed away at 78y/o from a myocardial infarction. History of Hypertension and high cholesterol.
Sister: 14 y/o. History of asthma Brother:
25y/o. No medical history Social History:
Tina is a pleasant young African American woman who was born in Shadowville. She does not currently have a significant other and is not sexually active. She denies a history of STD’s and uses condoms as protection. She lives at home with her mom and feels safe there. She describes her diet as good and avoids sugars. She has noticed an increase in her water intake and does
drink four diet cokes a day. She does not exercise but she likes to go out to the clubs with her friends and dance. She has minimal stress and gets 6-8 hours of sleep a night. She denies the use of tobacco. Denies the use of illicit drugs. She drinks alcohol about 1-2x/wk socially and has 2-3 drinks at a time. She is up to date on all her immunizations and has health insurance through her job as a supervisor at mid-American copy and ship........ Continue
