Name: Anna Jones | Pt. Encounter Number: 5663 | |
Date: 9/13/22 | Age: 54 | Sex: Female |
SUBJECTIVE | ||
CC:
“low back pain radiating to left leg”
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HPI:
54 yo female presents to the office today c/o lower back pain radiating down L buttock, down the left leg through the calf. Began 3 days ago, with sudden onset while she was at work, following lifting and turning a patient.. She reports feeling a “pop” followed immediately by this pain. States the pain is constant and worsening and rates severity as 7/10. Describes the pain as throbbing, with stinging and tingling down the left leg and calf and reports she “feels crooked”. She has tried rest and Ibuprofen to treat the pain but has gotten no relief. She reports sitting worsens the pain and she is unable to walk without pain. Denies history of similar symptoms. No recent trauma. No previous treatment or testing related to this problem. |
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Medications: Ibuprofen 400mg as needed for back pain
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Allergies: NKDA
Medication Intolerances: none reported |
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Past Medical History: Uterine fibroids
Chronic Illnesses/Major traumas: denies
Hospitalizations/Surgeries: 3 live births, partial hysterectomy due to uterine fibroids
Preventive : Immunizations up to date .Tdap 2015, Flu 2019, COVID #1 Jan 2020, COVID#2 Feb 2020. Yearly dental exam. Mammogram March 2020.
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Family History
Mother deceased due to COVID with history of asthma and smoking. Father living, age 86, HTN-controlled, smoker, depression.
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Social History
Pt attended tech school and is working full time as a nursing assistant. Married and monogamous with husband. She has 3 children. Owns home and feels safe there. Denies smoking, tobacco or recreational drug use. Reports occasional use of wine.
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ROS Student to ask each of these questions to the patient: “Have you had any…..” | ||
General
Denies weight change, fatigue, fever, chills, night sweats, or change in energy level
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Cardiovascular
Denies chest pain, palpitations, edema. |
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Skin
Denies rashes, bruises or bleeding, or change in skin lesions. |
Respiratory
Denies cough, SOB. |
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Eyes
Denies visual changes
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Gastrointestinal
Denies abdominal pain, N/V/D, constipation, eating disorders or ulcer
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Ears
Denies ear pain or hearing loss.
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Genitourinary/Gynecological
Denies dysuria or incontinence. Reports last PAP 2010, normal. 3 live births.
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Nose/Mouth/Throat
Denies congestion or sinus problems. Denies nosebleed. Denies dental disease. Denies sore throat or hoarseness
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Musculoskeletal
Reports throbbing lower back pain, radiates to Left buttock and down to left leg/calf for 3 days. Worsening and causing pain when ambulating. Not relieved by rest, position change or Ibuprofen. Denies history of similar problems. Denies joint swelling or history of arthritis. |
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Breast
Reports regular SBE, Denies lumps or mass. Last mammogram March 2020 |
Neurological
Alert and oriented x 4. Denies syncope, seizures. Reports stinging and tingling down left calf but denies numbness. |
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Heme/Lymph/Endo
Denies swollen or painful nodes, denies temperature intolerance, night sweats . |
Psychiatric
Denies depression. Reports anxiety and feeling overwhelmed, but no previous evaluation or treatment. States she self-medicates with exercise or occasional wine. |
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OBJECTIVE | ||
Weight 110lbs BMI 17.8 | Temp 98.3 | BP 115/80 left, 116/82 right |
Height 5’6’’ | Pulse 76 | Resp 24 O2 sat 99% |
General Appearance
Healthy-appearing adult female in no acute distress. |
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Skin
Skin warm, dry, clean, and intact. No rashes or lesions noted. |
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HEENT
Head is normocephalic, atraumatic.. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TM pearly gray, no bulging. Nose: Nasal mucosa pink; normal turbinates. Neck: Supple. Full ROM. No lymphadenopathy. Oral mucosa, pink and moist. Teeth are in good repair. |
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Cardiovascular
S1, S2 with regular rate and rhythm. No clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema. |
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Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. |
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Gastrointestinal
BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly. |
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Breast
Deferred. |
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Genitourinary
No CVA tenderness. No incontinence during visit.
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Musculoskeletal
Reduced forward flexion of lumbar spine. Left straight leg raise limited to 45 degrees. Left leg sciatic stretch test positive. Reduced response to light touch and pin prick lateral and dorsal left calf. Grade 4 weakness on dorsiflexion of left foot. Reduced right ankle jerk reflex. Negative reversed straight leg raise. Normal curvature of cervical, thoracic and lumbar spine. Gait slow and guarded. Spinal processes nontender. On standing, left shoulder appears higher than right. Full ROM of upper extremities. |
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Neurological
Oriented x 4 and answers questions appropriately. Speech clear. |
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Psychiatric
Maintains eye contact. Speech is of normal rate and cadence. Normal mood and affect. |
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Lab Tests/Imaging
MRI- normal Xray- normal
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Assessment | ||
· Include at least three differential diagnoses-acute low back pain, sciatica, herniated disc
· Provide rationale for each differential diagnosis · Final diagnosis -Acute low back pain, sciatica · Pathophysiology of primary and rationale for choosing as final
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Plan | ||
· Medications
· Non-pharmacological recommendations · Diagnostic tests · Patient education · Culture considerations · Health promotion · Referrals · Follow up |