Advanced Physical Assessment –
Musculoskeletal | Shadow Health
Complete Assessment & Documentation
| Verified Answers & Study Guide |
2026/2027
PART 1: PATIENT PROFILE & CHIEF COMPLAINT
Patient Demographics
• Name: Tina Jones
• Age: 28 years old
• Gender: Female
• Ethnicity: African American
• Setting: Hospital/Clinical environment for physical therapy consultation
Chief Complaint
• Primary Issue: Low back pain that "really hurts and doesn't seem to be going
away"
• Functional Impact: Pain is making it "kind of hard to get things done"
• Purpose of Assessment: Physical therapy consultation scheduled today;
musculoskeletal exam needed so therapist can understand Ms. Jones'
musculoskeletal health and customize therapy accordingly
PART 2: HISTORY OF PRESENT ILLNESS (HPI)
,Onset & Duration
• Pain began 3 days ago
• Constant since onset - "It's been there the whole three days" and "it hasn't
stopped"
• Mechanism: Patient "tweaked" back when lifting a box
• No previous history of back pain - "No, never"
Pain Severity
• Initial pain rating (at time of injury): 6-7 out of 10
• Current pain rating: 5 out of 10
• Pain has improved from initial injury but still "pretty bad"
Pain Location
• Lower back (lumbar region)
• Bilateral buttocks
• NO radiation down legs
• NO migration of pain
• Denies neck pain
• Denies pain between shoulder blades
Pain Characteristics
• Current character: Aching pain with stiffness
• Initial character: Sharp pain at onset
• Neuropathic symptoms: Denies burning pain - confirms non-neuropathic pain
Pain Patterns - OLDCARTS Framework
Component Finding
Onset 3 days ago, lifting a box
, Component Finding
Location Lower back and bilateral buttocks
Duration Constant, 3 days
Character Aching with stiffness (initially sharp)
Aggravating Sitting (worst), walking, bending
Relieving Lying flat on back, rest, ibuprofen
Timing Constant, worse with movement
Severity Current 5/10; Initial 6-7/10
Aggravating Factors
• Sitting: "Sitting is the worst. I'm least comfortable when I'm sitting" - clinically
significant as sitting increases intradiscal pressure
• Walking: Moving around makes it hurt more
• Bending: Increases pain
Relieving Factors
• Lying flat on back: Most comfortable position
• Rest: Slight pain relief
• Ibuprofen: Helps for a few hours
• Denies using heat or ice
PART 3: MEDICATION HISTORY
Musculoskeletal | Shadow Health
Complete Assessment & Documentation
| Verified Answers & Study Guide |
2026/2027
PART 1: PATIENT PROFILE & CHIEF COMPLAINT
Patient Demographics
• Name: Tina Jones
• Age: 28 years old
• Gender: Female
• Ethnicity: African American
• Setting: Hospital/Clinical environment for physical therapy consultation
Chief Complaint
• Primary Issue: Low back pain that "really hurts and doesn't seem to be going
away"
• Functional Impact: Pain is making it "kind of hard to get things done"
• Purpose of Assessment: Physical therapy consultation scheduled today;
musculoskeletal exam needed so therapist can understand Ms. Jones'
musculoskeletal health and customize therapy accordingly
PART 2: HISTORY OF PRESENT ILLNESS (HPI)
,Onset & Duration
• Pain began 3 days ago
• Constant since onset - "It's been there the whole three days" and "it hasn't
stopped"
• Mechanism: Patient "tweaked" back when lifting a box
• No previous history of back pain - "No, never"
Pain Severity
• Initial pain rating (at time of injury): 6-7 out of 10
• Current pain rating: 5 out of 10
• Pain has improved from initial injury but still "pretty bad"
Pain Location
• Lower back (lumbar region)
• Bilateral buttocks
• NO radiation down legs
• NO migration of pain
• Denies neck pain
• Denies pain between shoulder blades
Pain Characteristics
• Current character: Aching pain with stiffness
• Initial character: Sharp pain at onset
• Neuropathic symptoms: Denies burning pain - confirms non-neuropathic pain
Pain Patterns - OLDCARTS Framework
Component Finding
Onset 3 days ago, lifting a box
, Component Finding
Location Lower back and bilateral buttocks
Duration Constant, 3 days
Character Aching with stiffness (initially sharp)
Aggravating Sitting (worst), walking, bending
Relieving Lying flat on back, rest, ibuprofen
Timing Constant, worse with movement
Severity Current 5/10; Initial 6-7/10
Aggravating Factors
• Sitting: "Sitting is the worst. I'm least comfortable when I'm sitting" - clinically
significant as sitting increases intradiscal pressure
• Walking: Moving around makes it hurt more
• Bending: Increases pain
Relieving Factors
• Lying flat on back: Most comfortable position
• Rest: Slight pain relief
• Ibuprofen: Helps for a few hours
• Denies using heat or ice
PART 3: MEDICATION HISTORY
