Musculoskeletal on Tina Jones
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. Review of Systems: 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
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
Plan
Provide Ms. Jones with materials detailing stretching techniques for the lower back. • Initiate treatment with ibuprofen 600 mg by mouth every six to eight hours with food as needed for pain for the next two weeks. She may use acetaminophen 500-1000 mg by mouth every 8 hours for breakthrough pain. • Ms. Jones can also use adjunct therapy of topical heat or ice per comfort TID-QID. • Educate on proper body mechanics and lifting techniques. • Educate on when to seek emergent care including loss of bowel or bladder function, acute changes in sensation of lower extremities, or limitations in movement of lower extremities. • Return to clinic in two weeks for follow up and evaluation of symptoms.
