NR 511 Assignment – Back Pain

NR 511 Assignment – Back Pain

Patient information

Mr. T.Z is 73 years, Male, Caucasian, retired Greyhound driver, United Health Insurance

Subjective:

Chief Complaint: The patient complains of painful back pain that is not getting better for past four days ago.

Onset: four days ago

Location: A non-radiating pain in the lower left back

Duration: constant pain

Characteristic: Non-radiating pain that sometimes aching

Aggravating Factors: Bending or upright standing for at least 20 minutes

Alleviating Factors: Sitting in a recliner chair and taking OTC Ibuprofen 400mg PO BID

Treatment: OTC Ibuprofen 400mg PO BID

Severity: The pain is rated 7/10 on a patient self-rating scale, the patient indicates this is not a usual back pain like he has experienced in the past.

Allergies: No known foods, drugs, or environmental allergy

HPI:                                         

Mr. T.Z is a 73years old male Caucasian; he came to the clinic due to a non-radiating lower back pain that is aching for four days ago. The patient verbalizes that standing and bending over usually making the situation worse while sitting on a recliner chain or taking 400mg ibuprofen by mouth twice daily relieved the situation. The states” the pain is not on like the back pain he experienced a couple of years back in 2013”.

Past Medical History: The patient denies known childhood illness, immunization is up to date, last tetanus shot 10/12/2016, influenza vaccine 12/05/2017. The patient last hospitalization is for a surgical procedure in 03/05/2017 for gallbladder removed due to cholelithiasis, dental and oral care 04/04/2018. The history last back pain in 2013 is due to pulling a heavy object.

Social History: The patient is a retired Greyhound driver who lives with his wife of 52years of marriage and childless. He quit smoking five years ago, denies alcohol, street or illicit drug use. The patient hobbies are gardening and home repair.

Family History: The patient is the only one remaining of his father and mother family. Denies family history of high blood pressure, hypercholesterolemia, but admit to diabetes.  What the patient said his mother and father die at the age of 90 years of unknown cause. The patient sibling died in a motor vehicle accident about ten years ago.

ROS (Jarvis, 2016)

 Constitutional:

HEENT :

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NR 511 Assignment – Back Pain