Denies abdominal pain, N/V/D, constipation, eating disorders or ulcer

Name:  Anna Jones  Pt. Encounter Number: 5663
Date: 9/13/22 Age: 54 Sex: Female

“low back pain radiating to left leg”



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.

Medications: Ibuprofen 400mg as needed for back pain


Allergies: NKDA


Medication Intolerances: none reported

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.



Family History

Mother deceased due to COVID with history of asthma and smoking. Father living, age 86, HTN-controlled, smoker, depression.


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.


ROS Student to ask each of these questions to the patient: “Have you had any…..”

Denies weight change, fatigue, fever, chills, night sweats, or change in energy level



Denies chest pain, palpitations, edema. 


Denies rashes, bruises or bleeding, or change in skin lesions. 


Denies cough, SOB.


Denies visual changes



Denies abdominal pain, N/V/D, constipation, eating disorders or ulcer



Denies ear pain or hearing loss.



Denies dysuria or incontinence. Reports last PAP 2010, normal. 3 live births.



Denies congestion or sinus problems. Denies nosebleed. Denies dental disease. Denies sore throat or hoarseness



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.


Reports regular SBE, Denies lumps or mass. Last mammogram March 2020


Alert and oriented x 4. Denies syncope, seizures. Reports stinging and tingling down left calf but denies numbness.


Denies swollen or painful nodes, denies temperature intolerance, night sweats .


Denies depression. Reports anxiety and feeling overwhelmed, but no previous evaluation or treatment. States she self-medicates with exercise or occasional wine.

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.


Skin warm, dry, clean, and intact. No rashes or lesions noted.


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.


S1, S2 with regular rate and rhythm. No clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema.


Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.


BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly.




No CVA tenderness. No incontinence during visit.



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.


Oriented x 4 and answers questions appropriately. Speech clear.


Maintains eye contact. Speech is of normal rate and cadence. Normal mood and affect.

Lab Tests/Imaging

MRI- normal

Xray- normal


· 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


· Medications

· Non-pharmacological recommendations

· Diagnostic tests

· Patient education

· Culture considerations

· Health promotion

· Referrals

· Follow up

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