Tina Jones tweaked her back lifting a box
Week 3 Shadow Health Assessment Musculoskeletal
Subjective:
HPI: Ms. Jones presents to the clinic complaining of back pain that 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 of the box that caused her pain. The pain is in her low back and
bilateral buttocks, is a constant aching with stiffness, and does not 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 treated 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,
muscle weakness, bowel or bladder incontinence. She presents today as the pain has continued and is
interfering with her activities of daily living.
Social History: Ms. Jones’ job is mostly supervisory, although she does report that she may have to sit or stand
for extended periods of time. She denies lifting at work or school. She states that her pain has limited her
activities of daily living. She denies use of tobacco, alcohol, and illicit drugs. She does not exercise.
ROS: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. •
Musculoskeletal: Denies muscle weakness, pain, joint instability, or swelling. She does state that she has
difficulties with range of motion. She does state that the pain in her lower back has impacted her comfort while
sleeping and sitting in class. She denies numbness, tingling, radiation, or bowel/bladder dysfunction. She
denies previous musculoskeletal injuries or fractures. •
Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or
seizures.
OBJECTIVE:
ROS: General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is
alert and oriented. She maintains eye contact throughout interview and examination.
Musculoskeletal: Bilateral upper extremities without muscle atrophy or joint deformity. Bilateral upper
extremities with full range of motion of shoulder, elbow, and wrist. No evidence of swollen joints or signs of
infection. Bilateral lower extremities without muscle atrophy or joint deformity, full range of motion of
bilateral hips, knees, and ankles. No evidence of swollen joints or signs of infection. Flexion, extension, lateral
bending, and rotation of the spine with reduced ROM - pain and difficulty. Bilateral upper extremity strength
equal and 5/5 in neck, shoulders, elbows, wrists, hands. Bilateral lower extremity strength equal and 5/5 in hip
flexors, knees, and ankles.
ASSESSMENT: Low back muscle strain related to lifting
Med C
