I human Documentation_Note_3 for Beatrice Barlow complete
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Course
NURS 473
Institution
University Of Nevada-Las Vegas
Beatrice Barlow 53 Y/O female
Subjective
CC: “I am having terrible back pain; I must have thrown my back out”
HPI: Beatrice Barlow is a 53 y/o female that presents to the clinic for evaluation of bilateral lower back pain that is severe 10/10, sharp, and constant. The pain started 3 ...
CC: “I am having terrible back pain; I must have thrown my back out”
HPI: Beatrice Barlow is a 53 y/o female that presents to the clinic for evaluation of bilateral
lower back pain that is severe 10/10, sharp, and constant. The pain started 3 days ago after lifting
a laundry basket full of wet clothes. She reports that the pain radiates down her RLE to her foot.
She denies a history of any trauma, and states that she cannot perform daily activities due to the
pain.
Onset: 3 days
Characteristics: stabbing, gnawing
Aggravating/Alleviating: aggravating with movement, mildly alleviated with ibuprofen to 8/10
pain
Relieving: Ibuprofen
Treatments: None
Timing: constant
Severity: 10/10
PMH: HTN for 9 years ago well controlled, left mastectomy 5 years ago with radiation and
chemotherapy treatment for intraductal carcinoma, menarche at 10 y/o, menopause at 48 y/o
after chemotherapy, G2P2- first pregnancy at 33, tubal ligation at 40.
Allergies: none
Medication: OTC Ibuprofen, HCTZ for BP (dosage needed)
Surgeries: mastectomy 5 years ago, tubal ligation 13 years ago
OB: G2P2
Health Maintenance: Should have gotten information
FH:
Children: Alive and healthy
Mother: Died at 55 of breast cancer, metastatic disease
Dad: Unknown
MGM: Unknown
MGF: Unknown
PGM: Unknown
PGF: Unknown
SH:
Elementary school principal, married 27 years, 2 daughters age 18 and 20,
EtOH: rare (What is rare? Can be very different from person to person)
Caffeine: minimal (same as above)
Smoker: Never
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