Identifying Data:

Name: Ms. R

Sex: Female

Address: Arverne, NY

Date of Birth: 7/14/1967, 54 years old

Date & Time: 10/08/21, 10:00 AM

Location: Southshore Family Medical, Arverne, NY

Marital Status: Single

Race: African American

Source of Information: Self

Reliability: Reliable

Mode of Transport: Car

Chief Complaint: “my back hurts” x 1 week

History of Present Illness: 

55 y/o African American female with PMH of HTN, Type 2 DM, HLD, presents for left lumbar pain x 1 week. Pt states the pain began suddenly when she woke up in the morning, is constant, sharp and radiates down her left leg, and has been gradually worsening. She states the pain is aggravated by coughing, breathing, and sitting, and is alleviated by walking and heat compresses. She rates the pain as 10/10 when sitting and 5/10 when walking. Pt states she took ibuprofen 800 mg with no relief. Pt also admits to feeling “gassy” and bloated in her back, which improves slightly when she passes gas, but comes back. States she has been having diarrhea twice a day. Pt works as a CNA in nursing home, but is generally careful not to strain her back, and states she was not doing anything physically straining prior to the pain. Denies pain with urination, generalized weakness/ fatigue, fever, HA, CP, SOB, abdominal pain, nausea, vomiting, cough, sore throat, nasal congestion. 

Past Medical History:

Present medical illnesses – HTN, Type 2 DM, HLD

Past Illnesses- none

Childhood illnesses – none

Immunizations – Up to date

Screening Tests- none

Blood Transfusions- none

Past Surgical History: none

Medications:

1. Ergocalciferol 5000 Unit, 1 capsule Po, 1x/ week, for Vitamin D deficiency
2. Carvedilol 12.5 Mg tablet PO, QD, for HTN
3. Metformin Hcl 850 Mg Tablet, 1 tablet with a meal PO, 2x/day, for DM2
4. Januvia 100 Mg Tablet, 1 tablet PO, QD, for DM2
5. Fish Oil 1000 MG Capsule, 1 capsule PO 2x/day, for HLD
6. Fenofibrate 67 MG Capsule 1 tablet with food PO, QD, for HLD
7. Lipitor 40 Mg tablet, 1 tablet PO QD, for HLD

Allergies:

No known food, drug, or environmental allergies.

Family History:

Mother – deceased at age 76, hypertension, DM2

Father – deceased at age 35 from MI, had hypertension

Daughter- 35- alive and well

Son- 27- alive and well

Daughter- 24, alive and well

Daughter- 22- alive and well

Maternal/paternal grandparents – Deceased at unknown age and unknown reasons

Social History:

Mrs. H is a 54 y/o single female. She is a certified CNA in a nursing home. She lives at home with her 2 younger daughters.

Habits – Patient drinks one cup of coffee every morning. Admits to smoking 15 pk/years. Denies ETOH use, use of e-cigarettes or any illicit drug use. 

Travel- Denies any recent travel.

Safety- Admits to wearing seat belt.

Sleep – Admits to sleeping well, for about 7 hours every night.

Exercise – States that walks about 30 minutes every day.

Diet- Patients maintains a balanced diet, including fruits and vegetables.

Sexual History: Monogamous, denies being currently sexually active. Denies history of sexually transmitted infections.

Patient had COVID Moderna Vaccine, one in January and second in early February

Review of Systems:

General – Denies loss of appetite, recent weight loss or gain, current generalized weakness, fatigue, fever, chills, or night sweats.

Skin, hair, nails –Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies dizziness, headaches, vertigo or head trauma, unconsciousness, head fracture or coma.

Eyes –Patients admits to use of contacts. Denies visual disturbances, fatigue, lacrimation, photophobia, and pruritus. Last eye exam last January- normal.

Ears –Denies ear pain, discharge, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat – Denies sore throat, sore tongue, bleeding gums, mouth ulcers, voice changes. 

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Breast- Denies lumps, nipple discharge, and pain.

Pulmonary system – Denies dyspnea, shortness of breath, cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis or hemoptysis.

Cardiovascular system – Admits to hypertension. Denies chest pain, palpitations, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal system –Admits to flatulence and diarrhea. Denies changes in appetite, intolerance to foods, abdominal pain, nausea, vomiting, constipation, dysphagia, pyrosis, eructation, jaundice, hemorrhoids, rectal bleeding, or blood in stool. 

Genitourinary system –Denies urinary frequency, urgency, polyuria, oliguria, nocturia, incontinence, dysuria, hesitancy, dribbling, or flank pain.

Musculoskeletal system –Admits to left lumbar pain. Denies muscle/joint pain, arthritis, deformity or swelling, or redness.

Nervous System–Denies seizures, loss of consciousness, ataxia, loss of strength, change in sensation/tingling/ numbness, change in cognition / mental status / memory, or asymmetric weakness.

Peripheral vascular system –  Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, or color changes.

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.

Endocrine system –Denies polyuria, polyphagia, polydipsia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric –Denies depression, anxiety, OCD or ever seeing a mental health professional.

 Physical Exam

General: 54 year old female, alert and oriented to person, place and time. Patient is of average build, is well dressed, well groomed, and has good hygiene. Patient appears in moderate distress, is seen pacing around the room with poor posture.

Vital Signs: BP: 122/64, sitting                      

R: 16 breaths/min unlabored     

P: 90 beats/min, regular       

T: 98.2 Degrees F (oral)                      

O2 Sat: 98% on Room air

Height: 64 inches            Weight: 128 pounds        BMI: 22.0

Skin- Warm and moist, smooth, good turgor, nonicteric. No lesions, masses, scars, tattoos, thicknesses or opacities.

Hair- average quantity and distribution. Coarse, no lice or seborrhea noted.

Nails- Normal color size and shape of the nails. No spooning, clubbing, beau’s lines fissures, paronychia noted. Capillary refill <2 seconds throughout hands and toes.

Head-Atraumatic, normocephalic. Nontender to palpation on the frontal, temporal, occipital, and parietal areas. No deformities or specific faces noted.

Thorax & Lungs 

Chest – Symmetrical, no deformities, no evidence of trauma. Respirations are unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non- tender to palpation. 

Lungs – Clear to ausculatation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical.

Abdomen-Abdomen flat and symmetric with no striae, scars or pulsations noted. Bowel sounds hyperactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Abdomen soft and slightly tender to palpation across all 4 quadrants, no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Heart-Regular rate and rhythm. No splitting of S2 or friction rubs appreciated. Carotid pulses are 2+ bilaterally without bruits.

Mental Status Exam- patient is alert, attentive, and oriented. Speech and language are clear and fluent with good word comprehension. Appears to be in good mood, has insight and judgment into her medical problems. Memory and cognitive ability intact, gave accurate information upon assessment of history.

Peripheral Nervous System-

Motor/Cerebellar-Tender to palpation on left lumbar area. Full active/passive ROM of all extremities. Straight leg raise negative. Symmetric muscle bulk, no atrophy, tics, tremors or fasciculation. Strength 5/5 throughout upper and lower extremities bilaterally. Good gait, romberg negative, no pronator drift noted. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis.

Sensory-Intact to light touch, sharp/dull, and vibratory sense throughout.   Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.

Reflexes-2+ throughout.

Peripheral Vascular Exam- no edema, equal in circumference, no calf tenderness. Skin normal in color and warm to touch upper and lower extremities bilaterally. . No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy. No cyanosis, clubbing / edema noted bilaterally.

 Labs/ Imaging

Urinalysis in office- negative for leukocytes, nitrites, ketones 

Assessment

Mrs. R is a 55 y/o African American female with PMH of HTN, Type 2 DM, HLD, presents for left lumbar pain x 1 week, as well as bloating, flatulence, and diarrhea. Her exam was normal mainly normal excluding left lumbar tenderness to palpation, hyperactive bowel sounds, and slight diffuse abdominal tenderness.

Differential Diagnoses

1. Muscle Strain- has unilateral back pain and tenderness, painful motion
2. Sciatica- has back pain that radiates down her left leg. Sciatica is typically one-sided. But, straight leg raise was negative. 
3. Herniated Disc-has back pain that radiates down her left leg. But, straight leg raise was negative. 
4. UTI/pyelonephritis- has unilateral back pain. But no CVA tenderness, dysuria, frequent urination, cloudy urine, fatigue, fever, abdominal pain. In office UA was clear.
5. Nephrolithiasis- has unilateral back pain, as well as gassiness and diarrhea. But no fever, nausea, vomiting.
6. Irritable Bowel Syndrome- back pain, gassiness, and diarrhea. But, no abdominal pain, constipation, nausea. 

Plan: 

1. Low back pain- start methylprednisolone 4 mg Qd for 6 days, for pain and inflammation. Start cyclobenzaprine Hcl tablet, 10 mg, 1 tablet QHS as needed, PO, for 30 days (muscle relaxant), send urinalysis to lab for culture
2. Gas Pain-  famotidine tablet 20 mg, 1 tablet QHS as needed, PO for 30 days
3. Hypertension- stable, continue carvedilol
4. Type 2 DM- no acute complaints, continue metformin and januvia, remind about low sugar/ carb diet and exercise
5. Hyperlipidemia- no acute complaints, continue fish oil, fenofibrate, and lipitor
6. Vitamin D Deficiency- no acute complaints, continue calciferol
7. Smoking/ nicotine dependence- counsel about importance of smoking cessation