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 lifting heavy boxes. According to the patient
she “tweaked her back” while helpin
...
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 lifting 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.
ROS: General: She denies changes in weight, denies fatigue, weakness, fever, and chills.
Musculoskeletal: Denies numbness and tingling. Denies any loss of bowel and bladder
control. She does report lower pain with limited range of motion (ROM). According to
patient she has not had any prior back injuries. Neuro: Denies any numbness, tingling,
loss of sensation, paralysis, and has no history of seizures.
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TINA JONES GI ASSESSMENT 3
Pertinent Physical Exam Findings
VS: BP 141/80 HR 88 RR 14 T 99.2 Pulse Ox 99%
Tina Jones is a pleasant 28-year-old obese African American woman who presents to
clinic with complaint of lower back pain that began three days ago. She does not appear to be in
any acute distress now, however, reports that her pain is currently a 5/10 despite the use of
ibuprofen approximately every 5 to 6 hours. The pain is interfering with her ADL’s, she has
mother and sister to help at home. Ms. Jones is a good historian and is relaying all the
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