*NURSING > CASE STUDY > Running head: MUSCULOSKELETAL ASSESSMENT 1 Musculoskeletal Assessment Flora Flores Colorado Technica (All)

Running head: MUSCULOSKELETAL ASSESSMENT 1 Musculoskeletal Assessment Flora Flores Colorado Technical University

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Musculoskeletal Assessment Significant History Findings Tina Jones is a pleasant 28-year-old African American woman who presented to the clinic with lower back pain that began 3 days ago after lift... ing heavy boxes. According to the patient she “tweaked her back” while helping a friend move. Prior to the incident three days ago she denies any back pain. She currently rates her pain 5/10 and has taken ibuprofen to help manage her pain, while the ibuprofen does provide some relief it does not completely go away. The patient states that her pain does not radiate and is in the lower back area and bilateral buttocks. She reports that her pain is a constant ache with stiffness. Sitting makes her pain worse (7/10) and laying down to rest helps decrease her pain to (3-4/10). The pain has not improved and is now interfering with her activities of daily living (ADL’s). She denies any loss of bowel or bladder control and denies any numbness and tingling. Social History: Tina works in a supervisory role and is on her feet most of the day but sits sometimes. She reports that she does not lift anything heavy at work. The lower back pain causes her discomfort even while at rest and discomfort at school when she must sit. She lives at home with her mother and sister who help her since the pain is now interfering with her ADL’s. She denies the use of illegal substances and drinks socially. [Show More]

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