• Patient: Ava Jones

• Age: 22

• Height: 5'3"

• Weight: 115 lbs

• Complaints: Fatigue, stiffness in neck and lower back

• Observations: Normal vital signs, tense muscles upon palpation

• Patient exhibits difficulty moving neck and bending lower back

Based on the subjective and objective data, the patient is likely suffering from muscle strain in the neck and lower back. An intensive course of physical therapy sessions focusing on these areas is recommended to relieve the symptoms.

• Create a therapy plan targeting neck and lower back

• Schedule for therapy sessions twice a week

• Patient to be re-evaluated after two weeks