CLIN2505 Madeira Kayla Jack Si is a 55 year old black male who is self employed as a painter and complaining of back

pain as well as neck pain. Complaint #1. In 1970 he had a car accident that resulted in two separate MVAs. His pelvis was fractured. In the accident he was a pedestrian and he got struck by a car. Also in 1977 he was repelling from a helicopter in the Army and the VA diagnosis his problem as a muscle spasm but it got worse over the years. Rest, Ibuprofen, hot water, heating pad, moving a lot and lying on his left side helps his back problems. Prolonged standing, painting overhead and standing up from sitting down make the problem worse. He describes the pain as aching, throbbing when lying supine and stabbing when arising from a seated position. The pain radiates down both legs to the knees but anterior stops at the knees and posterior down the legs past the knee to the lateral aspect of the calve 2-3 inches below the knee. He never gets pain in his feet. The pain is most severe in his Left leg about a 8 out of 10 on the pain scale and the Right leg is about a 5 out of 10. The low back is aching throughout the entire lumbar region and burns in the middle of the lumber region about 1-2 inches in diameter. Pain worsens about the first 30 minutes upon waking up in the morning and also in the evenings. Compared to a year ago he feels as though his health is getting worse. The patient has Ear, lungs, Genitourinary and neurological issues that could be related to his problem. He had a stomach ulcer in 1976 and is on the medication R.A at 2000 mg. He had measles and chicken pox as a child. He wife was hospitalized in 2005 with a gastric disturbances. Both of his parents are deceased. Mother died of cervical CA at age 42 and father past at age 48 of cirrhosis of the liver. Has a family history of High blood pressure. He smokes 1 pack of cigarettes a day had has been since age 30. Jack Sleeps around 6 hours at night and has a active job painting but his diet is not good. He has not yet recovered from alcoholism that we was diagnosed with in 1980. Patient was diagnosed in 2005 with Rheumatoid Arthritis and takes 800 mg of ibuprofen a day. Severe hearing loss in Right ear and has tubes in both. He fell in 2004 MD thought it was equilibrium problem. He also suffers from frequent urination up to 6-7 times per 8 hrs. Patient has skin problems which results as a rash on his neck and legs but the Gold bond OTC cream is helping. Complaint #2. Jack has had neck pain since 2007. He believes his problem started because of the overhead painting he does. Currently he feels as though is neck locks up and must use his hands to return it to normal. No past health issues prior to 2001. What helps the pain is beating on the muscles of his neck, heat pad, ibuprofen and a massage. What makes the pain worse is overhead painting. The pain is a 9 out of 10 on the pain scale and Jack says the pain is unbearable. He says there is no radiating pain but his Left arm gets tired. Patient points to the lateral cervical area region C3-C7 as well as the C2-C3 midline hwere he reports the throbbing is. It gets worse after working over head.