Shadow Health Reflection: Musculoskeletal And Neurological

Shadow Health Reflection: Musculoskeletal And Neurological

Shadow Health Reflection: Musculoskeletal And Neurological

  • Complete the ShadowHealth© Musculoskeletal and Neurological assignments

Professional Development

  • Write a 500-word APA reflection essay of your experience with the Shadow Health virtual assignment(s). At least two scholarly sources in addition to your textbook should be utilized. Answers to the following questions may be included in your reflective essay:
    • What went well in your assessment?
    • What did not go so well? What will you change for your next assessment?
    • What findings did you uncover?
    • What questions yielded the most information? Why do you think these were effective?
    • What diagnostic tests would you order based on your findings?
    • What differential diagnoses are you currently considering?
    • What patient teaching were you able to complete? What additional patient teaching is needed?
    • Would you prescribe any medications at this point? Why or why not? If so, what?
    • How did your assessment demonstrate sound critical thinking and clinical decision making?
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  • attachmentMusculoskeletal_EHR.pdf
  • attachmentMusculoskeletal_transcript.pdf
  • attachmentNeurological_Completed_ShadowHealth.pdf
  • attachmentNeurological_transcript.pdf

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

Return to Assignment (/assignments/313477/)

Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation

Subjective

This is a 28 yo pleasant african american female. She is the primary source of history and offers information freely. she speaks clearly and coherent and maintains contact throughout the exam. She presents to the clinic with c/o back pain for 3 days. Pain is 5/10, takes advil and pain reduces to 2-3/10. Her pain in her lower back and upper buttocks. Gets worse when she is laying down. Is able to perform her normal acitivities. Medication: Proventil, albuterol. advil for pain, PRN Med allergy: PCN: hives and rash Medical history: Diabetes no meds Asthma: on Proventil and albuterol. Controlled asthma with meds No surgical history. No hx of trauma No family history of musculskeletal system disease Family history of HTN and Diabetes

HPI: Ms. Jones presents to the clinic complaining of back pain th began 3 days ago after she “tweaked it” while lifting a heavy box while helping a friend move. She states that lifted several boxes before this event without incident and does not know the weight the box that caused her pain. The pain is in her low back and bilateral buttocks, is a constant aching with stiffness, and does n radiate. The pain is aggravated by sitting (rates a 7/10) and decreased by rest and lying flat on her back (pain of 3-4/10). The pain has not changed over the past three days and she has treat with 2 over the counter ibuprofen tablets every 5-6 hours. Her current pain is a 5/10, but she states that the ibuprofen can decrease her pain to 2-3/10. She denies numbness, tingling, mus weakness, bowel or bladder incontinence. She presents today as pain has continued and is interfering with her activities of daily liv Social History: Ms. Jones’ job is mostly supervisory, although sh does report that she may have to sit or stand for extended period time. She denies lifting at work or school. She states that her pai has limited her activities of daily living. She denies use of tobacc alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Musculoskeletal: Den muscle weakness, pain, joint instability, or swelling. She does sta that she has difficulties with range of motion. She does state tha pain in her lower back has impacted her comfort while sleeping a sitting in class. She denies numbness, tingling, radiation, or bowel/bladder dysfunction. She denies previous musculoskeleta injuries or fractures. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures.

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