M.P. a 60 year-old Caucasian female Last visit to this office was 10/15/2022. Her last visit was a follow-up for chronic cough. M.P. has been a cigarette smoker for over 25 years and reports t
M.P. a 60 year-old Caucasian female
Last visit to this office was 10/15/2022. Her last visit was a follow-up for chronic cough. M.P. has been a cigarette smoker for over 25 years and reports that she stopped smoking a year ago “cold turkey”. Presented to the office today because she has been experiencing diffuse bone pain over the past several years since menopause at age 48 and has been experiencing severe pain in her back for the past week. Complains that any weight bearing activity causes her severe discomfort. Has a difficult time standing for long periods of time.
CC: The diffuse pain in her back (spine) and hip has become more frequent and “keeps her from doing daily activities”.
Any weight bearing activity causes her severe discomfort. It is difficult to stand for long periods of time.
Onset: 3 weeks ago. Location: Had severe pain in my back when carrying grocery bags, standing for short periods of time and was unable to lift her grandchildren without back pain. Duration: Pain lasted for several hours. Characteristics: A stabbing pain that wouldn’t stop until I stopped my activities. Aggravating factors: Continuing to lift and carry heavy objects. Relieving factors: Getting off my feet and resting; Heating Pad and Extra Strength Tylenol. Timing: Constant until rested. Severity: Back and spine pain – 7-8/10 on pain scale.
PMH: Post menopausal since age 51
Hx of HTN; hypercholesterolemia, bronchitis, bladder prolapse and stress incontinence.
Current Medications
Quinipril/HCTZ 20/12.5 mg daily
Simvastatin/Zocor – 20 mg po daily at bedtime
Had 3 vaginal births without complication; no surgeries. Denies allergies to any medication, but suffers from seasonal allergies in the Fall and Spring
Smoker since age 35 – smoked 1 – 2 packs of cigarettes daily.
Centrum Silver – 1 tablet daily; Calcium Supplements with Vitamin D – 600 mg po bid daily for 2 years
Immunizations (Flu vaccine yearly; Tetanus 7 years ago; denies ever having the Pneumococcal Vaccine or Herpes Zoster vaccine)
FH:
Father: age 87; HTN; skin cancer
Mother: deceased age 79; HTN; DM Type 2; Osteoporosis
2 sisters – 1 alive & well age 65; 1 deceased at age 58 – breast cancer
3 adult children alive and well
SH:
Currently works as an Administrative Assistant at the local Middle School.
Married 35 years; 3 children and 1 grandchild
Lives with her husband in a 3 BR home for the past 15 years.
Denies use of any illegal drugs/substances.
Drinks alcoholic beverages (wine/beer) occasionally at family gatherings. Drinks 2 cups of coffee with caffeine and diet beverages daily
No exercise routine. Sedentary lifestyle
ROS: Pertinent Negatives
Denies headache, dizziness, fainting, vision change, blurred vision, eye pain.
Denies chest pain/pressure, SOB
Denies chest pressure or palpitations
Denies weakness, numbness, tingling of extremities
ROS: Pertinent Positives
Severe diffuse pain in upper and lower back
Unable to lift packages, children or any type of weight-bearing
Assessment Findings
Height 5’5″; Weight 125 BMI 21 (was 5’6″ 1 year ago)
T 98.6, P 80 regular; R 18 BP: R 130/72 L 132/72
Heart : No gallop, murmur or rub, RRR
Lungs: The chest wall is symmetric, without deformity, and is atraumatic in appearance. No tenderness upon palpation of the chest wall.
Back: Upon palpation guarding and tenderness are present in the cervical, thoracic and lumbar spine with limited ROM. Discomfort noted on palpation of back and spine. No presence of Dowager’s Hump. No evidence of herniation or disc displacement upon inspection. No scoliosis or lordosis present.
Extremities/ROM : Upper limbs limited ROM
CVA tenderness – Negative
Part 1:
Answer the following questions:
1. What are your concerns given this client presentation?
2. What are the contributing factors?
3. What is the focus of your PE and why?
4. What is the most likely working Diagnosis? What are the most likely DDX(s)?
5. What labs and/or diagnostic testing is necessary at this time? How are they related to the CC or H&P? 6. What is your management plan for this client? Include pharmacologic or pertinent therapies.
Part 2:
What are the potential complications of this illness?
How will you follow up with this client and why?
What patient education teaching will you provide?
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