NURS 653 Comprehensive Musculoskeletal Case Study_ Tina Jones | Actual
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NURS 653 Comprehensive AHA For the APRN ,Fall 2025 , NURS 653
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Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Provider Notes
Objective Data Collection
Document: Provider Notes
Education & Empathy
Documentation Student Documentation Model Documentation
Video Tutorial
HPI: Ms. Jones presents to the clinic complaining of back
Subjective
pain that began 3 days ago after she “tweaked it” while
lifting a heavy box while helping a friend move. She states
Chief complaint: "I have alot of pain in my lower back. It that lifted several boxes before this event without incident
really hurts, and it doesn't seem to be going away. It's and does not know the weight of the box that caused her
making it kind if hard to get things done, so I decided to pain. The pain is in her low back and bilateral buttocks, is
come in and have it looked at." a constant aching with stiffness, and does not radiate. The
pain is aggravated by sitting (rates a 7/10) and decreased
HPI: Ms. Tina Jones is a 28 year old African American by rest and lying flat on her back (pain of 3-4/10). The pain
female presenting with complaints of lower back pain that has not changed over the past three days and she has
began three days ago after lifting a box. She localizes the treated with 2 over the counter ibuprofen tablets every 5-6
pain to her lower back area and the top of her buttock hours. Her current pain is a 5/10, but she states that the
area, describing it as a dull ache without radiation. She ibuprofen can decrease her pain to 2-3/10. She denies
rates the pain as 5 out of 10 in severity. The pain is numbness, tingling, muscle weakness, bowel or bladder
aggravated by sitting upright, moving, bending, or incontinence. She presents today as the pain has
reaching for objects, which has limited her ability to continued and is interfering with her activities of daily
perform daily activities. She reports taking Advil 600mg up living.
to three times a day with partial relief. She denies any
previous history of back pain. Social History: Ms. Jones’ job is mostly supervisory,
although she does report that she may have to sit or stand
PMH: Diabetes, Asthma for extended periods of time. She denies lifting at work or
Allergies: Cats, Penicillin school. She states that her pain has limited her activities of
daily living. She denies use of tobacco, alcohol, and illicit
ROS: drugs. She does not exercise.
General: Denies fever, fatigue, weight changes
HEENT: Denies dizziness, vision changes, sore throat Review of Systems: General: Denies changes in weight,
Respiratory: Denies trouble breathing, cough, chest fatigue, weakness, fever, chills, and night sweats. •
tightness Musculoskeletal: Denies muscle weakness, pain, joint
Cardiac: Denies chest pain, palpitations instability, or swelling. She does state that she has
GI: Denies nausea, vomiting difficulties with range of motion. She does state that the
Muscle: Reports lower back stiffness and pain. Denies pain in her lower back has impacted her comfort while
joint pain, swelling or weakness elsewhere. sleeping and sitting in class. She denies numbness,
Neuro: Denies numbness, tingling or weakness. tingling, radiation, or bowel/bladder dysfunction. She
denies previous musculoskeletal injuries or fractures. •
Family History: No family history of musculoskeletal Neurologic: Denies loss of sensation, numbness, tingling,
disorders tremors, weakness, paralysis, fainting, blackouts, or
seizures.
Latest 2026 Test | Verified Solutions
Musculoskeletal Results | Turned In
NURS 653 Comprehensive AHA For the APRN ,Fall 2025 , NURS 653
Return to Assignment (/assignments/1235866/ )
Your Results Lab Pass (/assignment_attempts/20018145/lab_pass.pdf)
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Provider Notes
Objective Data Collection
Document: Provider Notes
Education & Empathy
Documentation Student Documentation Model Documentation
Video Tutorial
HPI: Ms. Jones presents to the clinic complaining of back
Subjective
pain that began 3 days ago after she “tweaked it” while
lifting a heavy box while helping a friend move. She states
Chief complaint: "I have alot of pain in my lower back. It that lifted several boxes before this event without incident
really hurts, and it doesn't seem to be going away. It's and does not know the weight of the box that caused her
making it kind if hard to get things done, so I decided to pain. The pain is in her low back and bilateral buttocks, is
come in and have it looked at." a constant aching with stiffness, and does not radiate. The
pain is aggravated by sitting (rates a 7/10) and decreased
HPI: Ms. Tina Jones is a 28 year old African American by rest and lying flat on her back (pain of 3-4/10). The pain
female presenting with complaints of lower back pain that has not changed over the past three days and she has
began three days ago after lifting a box. She localizes the treated with 2 over the counter ibuprofen tablets every 5-6
pain to her lower back area and the top of her buttock hours. Her current pain is a 5/10, but she states that the
area, describing it as a dull ache without radiation. She ibuprofen can decrease her pain to 2-3/10. She denies
rates the pain as 5 out of 10 in severity. The pain is numbness, tingling, muscle weakness, bowel or bladder
aggravated by sitting upright, moving, bending, or incontinence. She presents today as the pain has
reaching for objects, which has limited her ability to continued and is interfering with her activities of daily
perform daily activities. She reports taking Advil 600mg up living.
to three times a day with partial relief. She denies any
previous history of back pain. Social History: Ms. Jones’ job is mostly supervisory,
although she does report that she may have to sit or stand
PMH: Diabetes, Asthma for extended periods of time. She denies lifting at work or
Allergies: Cats, Penicillin school. She states that her pain has limited her activities of
daily living. She denies use of tobacco, alcohol, and illicit
ROS: drugs. She does not exercise.
General: Denies fever, fatigue, weight changes
HEENT: Denies dizziness, vision changes, sore throat Review of Systems: General: Denies changes in weight,
Respiratory: Denies trouble breathing, cough, chest fatigue, weakness, fever, chills, and night sweats. •
tightness Musculoskeletal: Denies muscle weakness, pain, joint
Cardiac: Denies chest pain, palpitations instability, or swelling. She does state that she has
GI: Denies nausea, vomiting difficulties with range of motion. She does state that the
Muscle: Reports lower back stiffness and pain. Denies pain in her lower back has impacted her comfort while
joint pain, swelling or weakness elsewhere. sleeping and sitting in class. She denies numbness,
Neuro: Denies numbness, tingling or weakness. tingling, radiation, or bowel/bladder dysfunction. She
denies previous musculoskeletal injuries or fractures. •
Family History: No family history of musculoskeletal Neurologic: Denies loss of sensation, numbness, tingling,
disorders tremors, weakness, paralysis, fainting, blackouts, or
seizures.
