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Name:  DB

Date: 1/13/2017

Time: 10:33AM

Age: 33

Sex: Female

SUBJECTIVE

CC: 

“My back hurts”. 

HPI:  (Use OLDCART)

She reports feeling pain in her lower back that started yesterday while at work. Last night she went to sleep as usual, when she woke up this morning she was in a lot of pain and was very stiff. The pain is described as a 7/10 on the pain scale, feels like burning. Pt states pain is worse in the R lumbo-sacral area. Pain radiated to her R buttock. It hurts her to stand up or to find a comfortable position. Pain worsens after bending or lifting. Her back hurts even at rest, but gets worse with movement. Taking Tylenol 500mg 2 caplets with no relief of the pain. Denies hx of UTI symptoms; Denies vaginal discharge or dyspareunia; denies change in bladder or bowel habits; denies weight loss or fever. Denies hx of previous back pain, injury or trauma. States she works as a cashier at the grocery store where she stands most of the day. Yesterday was her second day of working over time at work and she thinks since she works standing up, this might have cause for her to feel pain in her lower back. Denies muscle weakness, paresthesia, loss of sensations, and no severe or progressive neurological deficit in lower extremity. 

Medications: (list with reason for med )

Tylenol Extra Strength 500 mg Caplets, 2 tabs q4-6 hr for back pain with no relief

Metformin 500mg 1 PO QD for Type 2DM

Lisinopril 10mg 1 po QD for HTN

PMH

Allergies:   NKDA, denies food allergies

Medication Intolerances: Denies

Chronic Illnesses/Major traumas: HTN (2016), Type 2 NIDDM (2017)

Hospitalizations/Surgeries: Appendectomy (2001) 

Family History

States her parents (mother 59, father 63), siblings (sister 34, brother 27) and daughter- 4y/o are healthy and both sets of grandparents are alive and live in Colombia (doesn’t know age or if they have any medical problems).

Social History

General: Born and raised in Cali, Colombia, moved to the US with her parents when she was 17 years old.

Marital status: Single Mom of a 4-yr/old girl. Ex-husband not involved financially or physically in care of child.

Living situation: Parents live 100 miles away. One brother in town; sees brother seldom. Mrs. B has a few close friends. Pt sates she is in debt “way over head”. No health insurance benefits. Considers herself a strong and independent woman.

Children: One 4-yr/old daughter who is healthy

Occupation: Works at a local grocery store as a cashier. She stands most of the day in her job. Sees job only as a means of providing income for her and her daughter.

Leisure Patterns: Pt states she doesn’t have time to “relax”.

Social habits: Denies smoking or alcohol consumption. Does not exercise.

Spirituality: No church involvement but states that she believes in God.

Nutrition: Pt states her appetite has increased owing to “stress”, craves chocolate, eats what she wants, no special diet. Has not experienced any changes on her weight.

Sleep Patterns: States that she usually gets about 7 hrs of sleep every night.

ROS

General

States there have not been any changes in the past 5 years. He has been wearing the same size of clothes for the past 5 years. Denies weakness, fatigue, or fever.

Head: Denies headache, head injury, dizziness, or lightheadedness.

Cardiovascular

States she was just recently diagnosed with HTN, takes Lisinopril every night, states she checks her BP at least once a week when she goes to the grocery store and it is always below 130/80. Denies any troubles with her heart, rheumatic fever, or heart murmurs. Denies having chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or edema. Has never had EKG done.

Skin

Reports dryness of the skin, especially on his hands, legs and feet. Denies rashes, lumps, sores, itching, and changes in color. Denies changes in his nails or hair. Denies changes in size or color of moles.

Respiratory

Denies cough, sputum, hemoptysis, dyspnea, wheezing, or pleurisy. Has not had a Chest X Ray done. Denies having asthma, bronchitis, emphysema, pneumonia, or tuberculosis.

Eyes

Denies any changes in her vision. Does not use glasses. Last eye exam 2 years ago (Oct/15). Denies any pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma or cataracts. 

Gastrointestinal

Denies trouble swallowing, heartburn, changes in appetite, or nausea. States she has bowel movements every other day normally, the stools are small, brown and formed. Denies pain or bleeding with defecation. No changes in bowel habits. Denies black or tarry stools, hemorrhoids, constipation, or diarrhea. Denies abdominal pain, food intolerance or excessive belching or passing gas. Denies jaundice, live, or gallbladder trouble. Denies Hepatitis. Does not remember if she has received Hep B vaccine.

Ears

States she doesn’t have any hearing problems. Denies tinnitus, vertigo, earaches, infection, or discharge. Denies use of hearing aides. 

Genitourinary/Gynecological

Goes to the bathroom 4 or 5 times a day. Denies polyuria, nocturia, urgency, burning or pain during urination. Denies hematuria, urinary infections, kidney or flank pain, kidney stones, urethral colic, suprapubic pain, or incontinence. No changes in bladder habits.

Menarche at age 13. States she gets her period approx. q 28 days and it lasts about 5 days. Flow heavier on the first 2 days. Denies bleeding between periods. LMP: September 4th. Denies PMS. Denies any vaginal discharge, dyspareunia, itching, sores, lumps, or STDs. G1 P1, spontaneous vaginal delivery at 39 weeks. Denies any complications with her pregnancy. Denies use of birth control methods. Not sexually active at the moment. Has had one partner in the past 5 years. Denies exposure to HIV infection or STDs.

Nose/Mouth/Throat

 Pt states she gets occasional allergies and colds that cause her to have stuffiness and discharge. Denies hay fever, nose bleeding, or sinus trouble. Throat: States her teeth are yellow and sometimes her gums would bleed. Denies use of dentures. Last dental examination 2 yrs ago (Oct/15). Denies sore tongue, frequent sore throats or hoarseness. Denies having dry mouth or excessive thirst.

Neck: Denies swollen glands, goiter, lumps, pain, or stiffness in the neck.

Musculoskeletal

Denies muscle weakness, paresthesia, loss of sensations, no severe or progressive neurological deficit in lower extremity. No Hx of cancer, or risk factors for spinal infection (no IV drug abuse, UTI, Immune suppression). Pt reports feeling lower back pain that started yesterday while at work that is worse in the R lumbo-sacral area. Pain radiates to her R buttock. Pt states it hurts to stand up or find a comfortable position. States her back hurts even at rest, but pain gets worse when she moves. Pain worsens after bending or lifting. Denies other muscle or joint pain, stiffness, arthritis or hx of gout. Denies fever, chills, rash, anorexia, weight loss or weakness.

Breast

Denies lumps, pain, discomfort or nipple discharge.

Neurological

Denies changes in mood, attention or speech. Denies changes in orientation, memory, insight, or judgment. Denies headaches, dizziness, vertigo, fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or pins and needles, tremors or other involuntary movements.

Heme/Lymph/Endo

Denies anemia, easy bruising or bleeding, and past transfusions. Denies excessive thirst and hunger. Denies thyroid trouble, heat or cold intolerance, excessive sweating, polyuria or changes in shoe size. Denies weight changes or fever.

Periferal Vascular: Pt states she has a few spider veins that look like bruises, she got them during the pregnancy. Denies leg cramps, varicose veins, past clots in veins, swelling in calves, legs or feet. Pt states there have not been any changes in the color of her fingertips or toes during cold temperatures/weather. Denies any swelling or tenderness.

Psychiatric

Denies nervousness, tension, mood changes, depression, or memory changes.

OBJECTIVE

Weight  120lbs      BMI 20

Temp 98 F

BP 114/74

Height 67”

Pulse 89

Resp 20

General Appearance

Skin warm and dry w/o discoloration or pallor, A/O x 3, appropriate responses, cooperative, appears concerned w/o signs of acute distress.

Skin

Skin is warm, pink and supple, no lesions noted.

HEENT

Normocephalic, PERRLA, EOMs intact, fundoscopic: red reflex present, no nicking or hemorrhage. TM intact bilaterally, pearly with + light reflex. Nares patent, neck supple. Pharynx: swallows w/o difficulty, no erythema; Neck: thyroid non palpable, no carotid bruits.

Cardiovascular

Carotid upstrokes are brisk, w/o bruits. The PMI is tapping, 7cm lateral to the midsternal line in the 5th intercostal space. S1 louder than S2 on auscultation. No murmurs or extra sounds. Extremities are warm and w/o edema. No varicosities or stasis changes. Calves are supple and nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses are 2+ , brisk, and symmetric.

Respiratory

Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no rales, wheezes, or ronchi.

Gastrointestinal

Abdomen is flat with active bowel sounds in all four quadrants. It is soft and non-tender; no masses or hepatosplenomegaly. No CVA tenderness.

Breast

Deferred

Genitourinary

Deferred

Musculoskeletal

No joint deformities. Positive ROM in hands, wrists, elbows, shoulders, knees and ankles. Gait/Posture: Flexed forward at 15º, walked slowly with a wide based stance, and grimaced with movement. Heel and toe walking intact. Spinal column: No kyphosis, scoliosis or lordosis; unable to extend or rotate. Lateral movement: bilaterally to 20º. All attempts at ROM produced pain. Right paravertebral muscle spasm noted in lumbar area. Straight leg raise (SLR) negative, Patrick test negative, crossed SLR negative. No noted major motor weakness on knee extension, ankle plantar flexors, evertors, dorsiflexors. No CVA Tenderness.

Neurological

Cranial nerves II to XII intact. Good muscle bulk and tone. Strength 5/5 throughout. Rapid alternating movements and point to point movements are intact. Gait stable. Pinprick, light touch, position sense, vibration, and stereognosis intact, Romberg negative. Reflexes 2 + and symmetric with plantar reflexes down going.

Psychiatric

Alert, relaxed and cooperative. Thought process is coherent. Oriented to person, place and time.

Lab Tests

None ordered today.

Special Tests

 None ordered today.

 Diagnosis

  Diagnosis:

1. Acute lumbosacral strain (M54.5)

Differentials:

1. Acute lumbosacral pain (M54.5): Minimal discomfort initially followed by increased pain and stiffness 12-36 hrs later, SLR, crossed SLR, heel and toe walking were intact. No muscular weakness or loss of sensation. DTRs were equal and not depressed. Babinski negative. Spasm noted in paravertebral muscles.

2. Herniated lumbar disc (M51.2) : Pain in buttocks.

3. Sciatica (M54.3): Pain in back/buttocks.

4. Possible vertebral Fx (S32.009A): Low back pain.

Plan/Therapeutics

Plan: 

Diagnostic: No tests needed at this time

Therapeutic: Pharmacological:

D/C OTC Tylenol. Start Ibuprofen 600mg 1 po q8h x 7 days then PRN for pain. Robaxin 500mg 1 po QAM, 2 po QHS x 2 weeks then 1 po Q8H PRN for back pain.

Non-pharmacological:

Local application of ice may help initially to decrease pain, apply cold pack for 20 minutes q2-3 hours while awake. After 2-3 days, either heat or ice may be applied. No bed rest indicated. Take 3-7 days off work (her job would increase stress on her back), or perform other duties until the symptoms abate.

Patient Education:

1. Avoid jerky, hurried movements when lifting

2. Lift with legs by straddling the load; bend knees to pick up load; keep back straight (do not bend back)

3. Keep objects close to the body at navel level when lifting

4. Avoid twisting, bending, reaching while lifting

5. Avoid prolonged sitting

6. Change positions often while sitting

7. A soft support belt for the back, armrests to support some body weight, a slight reclining chair may make sitting more comfortable

8. Firm mattress/bed board, lying supine with hips and knees flexed on pillows is beneficial when sleeping

9. May return to work in 4-8 days

10. As soon as she returns to regular activities (in 2 weeks), aerobic conditioning exercises such as walking, swimming, stationary biking, or even light jogging may be recommended to avoid debilitation.

Referral: None

Follow-Up: Come back if the pain does not improve by 50% in 24-48 hrs. Return to the office in 7-10 days. Return sooner if neurological symptoms worsen or bowel/bladder dysfunction occurs.

 Evaluation of patient encounter:

I was able to assess the patient independently and then later present the case to my preceptor by providing her with the pertinent positive on the ROS and on the physical exam findings. I participated in the Dx selection and in the treatment plan.

Weaknesses: I must by managing my time. It took me almost 45 minutes to work on this case.

Strengths: I have improved my physical exam skills, I feel confident and comfortable interacting with patients on my own.

Reflection: I feel like I am improving with collecting enough information and with performing focused physical exams. I feel like everything is starting to fall in the right place.

Name: 

Date:

Time:

Age:

Sex:

SUBJECTIVE

CC: 

Reason given by the patient for seeking medical care “in quotes”

HPI:  Use OLDCART acronym

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.

Medications: (list with reason for med ) write medicine the same way you write a Rx

PMH (list approximate year of Dx of the disease or when surgical procedure performed)

Allergies:  

Medication Intolerances:

Chronic Illnesses/Major traumas

Hospitalizations/Surgeries

Family History (list immediate family, age, disease, and whether is dead or alive)

Does your mother, father or siblings have any medical or psychiatric illnesses?  Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.

Social History

Educa