Assignment 8.2: Shadow Health Pain Management
Assignment 8.2: Shadow Health Pain Management
Student Documentation. Model Documentation
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| CC: “My back is killing me” HPI: Tanner Bailey is a 30-year-old transgender man presenting to the clinic today with concerns of lower back pain. He reports low back pain that is described as sharp, burning, and tingling, resulting from an injury while he was lifting a heavy box about three and a half months ago. Pain onset was immediate after the injury. He reports he did not seek medical care after his injury due to wanting to save costs, see if the injury would heal independently, and avoid provider interactions due to a history of transphobic providers. Mr. Bailey is still having the back pain at present, and the pain is intermittent throughout the day. He reports that walking, bending, or lifting aggravates the pain. He reports partial alleviation of symptoms with sitting, lying down, rest, and using his friend’s hydrocodone medication. Mr. Bailey reports his pain is at 4-7 out of 10 when exacerbated and 0-2 out of 10 when controlled. He reports starting acetaminophen three and a half months ago following his injury, but discontinued this one week ago in order to safely use his friend’s hydrocodone prescription for pain. He has been taking the hydrocodone twice daily until running out this morning. He is now requesting a prescription for pain medication. Allergies: No known allergies. Medications: Testosterone enanthate 100 mg intramuscular once weekly for hormone supplementation/gender affirmation therapy. Past Medical History: Denies. Past Family History: Reports maternal depression and alcoholism. Social History: • Works as a theatre director and reports steady but low income. • Reports being a transgender man. • Reports wearing chest binder to affirm masculine identity. • Reports decreased alcohol use since sustaining injury due to staying at home. • Denies illicit substance use, tobacco use, or nicotine use. • Denies current sexual activity. Health Promotion/Immunizations: • Affirms all childhood vaccines. • Reports receiving coronavirus vaccine and influenza vaccine several months ago. Review of Systems: • Constitutional: Denies fever, chills, sweats, affirms weight loss. • Integumentary: Denies rash, swelling. • Neurological: Denies numbness, headache, bowel/bladder incontinence, affirms tingling in the back. • Musculoskeletal: Affirms low back pain, pain with ambulation, bending or lifting. | |
| Objective
Pain 7/10. Opioid brings pain to 2/10. NKDA. No Physical and Mental Health. Lower Back Pain – Started three and half months ago. Taking Acetaminophen and Norco 5-325mg for pain. Norco 5 (5mg hydrocodone & 325 Acetaminophen). Opioids – morning and nights. Take alcohol while out with friends. Occupation: Theater Director. Not working for months. Taking Testosterone for Trans-gender therapy. Taking weekly for two years. Mother drinks (alcoholic) and suffers depression. Normal BM. Normal Void. |
(No Model Documentation Provided) |
Objective  Struggling to meet your deadline ?Get assistance on Assignment 8.2: Shadow Health Pain Management done on time by medical experts. Don’t wait – ORDER NOW! Pain 7/10. Opioid brings pain to 2/10. NKDA. No Physical and Mental Health. Lower Back Pain – Started three and half months ago. Taking Acetaminophen and Norco 5-325mg for pain. Norco 5 (5mg hydrocodone & 325 Acetaminophen). Opioids – morning and nights. Take alcohol while out with friends. Occupation: Theater Director. Not working for months. Taking Testosterone for Trans-gender therapy. Taking weekly for two years. Mother drinks (alcoholic) and suffers depression. Normal BM. Normal Void. |
(No Model Documentation Provided) |
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