Reference no: EM134030383

Question

Ann Rails 24 years old, admitted for back pain. The injury, according to her report, occurred as a result of a domestic dispute in which she was pushed into a kitchen counter. She has no other significant medical history. No known allergies (NKA). Her last vital signs are blood pressure 124/82, temperature 98.2, pulse 84, respiration rate 22, Sp0, 96% on room air. She states she has had pain and numbness in her legs for one week. There is abnormal left leg weakness, gait unsteady, 5/10 on numeric pain scale. She is receiving Lortab 2 tabs every 6 hours, which she states relieves her pain. Her neuro assessment is within expected parameters, except for the leg pain upon movement. Activity as tolerated with assistance; we have asked her to call for assistance when getting out of bed. She is on a regular diet, but she has had very little intake since she has been here. Her children have visited, but we have not seen her partner since her admission. She has not made any further comment about them, other than her statement on admission that they caused her injury that she is afraid to go home. Discharge plan: decrease pain.