lOMoARcPSD| 45010774
I Human Case Week #7 A 53 Year Old Female
Reason For Encounter: Back Pain Comprehensive
Study Case
Reason for Encounter: A 53-year-old female presented today with complaints of back
pain.
History of Present illness: A 53-year-old female with PMHX of HTN, asthma and breast
cancer 5 year ago s/p mastectomy, chemo, radiation presented with constant lower
back pain for past three days ago. She describes as sharp, stabbing, and gnawing. She
rated 10/10 in intensity. She reported she was lifting a heavy laundry basket full of wet
clothes and that’s when pain started. It is worse when she moves. Pain radiated to right
leg and mostly in her thigh but sometimes all the way to her foot. She gets awaken from
sleep because of pain. She has taken Ibuprofen without relief. Associated symptoms
includes night sweats, weight lost about 20 pounds in last six months, feeling of fullness
of upper side of abdomen, right leg feels numb and tingling on the outside of her thigh.
Denies fever or chills, abdominal pain, fall, injury, redness swelling, muscle cramps.
Denies nauseas, vomiting, constipation, diarrhea.
Past Medical History: Hypertension, asthma, breast cancer
Hospitalizations / Surgeries: Surgeries: Mastectomy
Medications: Hydrochlorothiazide, fluticasone/salmeterol inhaler, prednisone, albuterol.
Allergies: NKA
Preventive health:
Family History:
Social History:
General: Positive for unintentional weight loss and night sweats, difficulty sleeping due
to pain. Denies fever with chills, fatigue.
Integumentary / Breast: Denies skin changes or moles changes; Denies breast
discharge or lumps; Denies scaly nipples, pain, swelling, or redness.
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HEENT / Neck: denies headache; No double or blurred vision; No difficulty with night
vision or problems hearing; Denies ear pain or sinus problems; Denies itchy scalp,
thinning hair, or brittle nails. No chronic sore throats or difficulty swallowing.
Cardiovascular: Denies chest pain, discomfort, or pressure; No pain/pressure/dizziness
with exertion; Denies blue/cold fingers and toes.
Respiratory: Denies shortness of breath or wheezing; Denies difficulty catching breath
or chronic cough; No sputum production.
Gastrointestinal: Denies nausea or vomiting; Denies dark tarry stool or bright red blood
in bowel movement; No early satiety or bloating.
Genitourinary: No pain, burning, blood, difficulty starting or stopping urination; Denies
dribbling or incontinence; No urgency during day or night or any changes in frequency.
Musculoskeletal / Osteopathic Structural Examination: Positive for lower back pain.
Denies muscle or joint pain; No redness, swelling, muscle cramps or joint stiffness, or
joint swelling; Denies neck, shoulder, or hip pain.
Allergic / Immunologic: Denies seasonal allergies or environmental allergies; Denies
hives or eczema.
Endocrine: Denies heat or cold intolerance; No increased sweating or increased thirst;
Denies frequent urination or change in appetite.
Hematologic / Lymphatic: Denies any bruising or bleeding gums; Denies nose bleeds or
other sites of increased bleeding; No history of anemia.
Neurologic: Denies dizziness, fainting, or spinning room; Denies seizures, weakness, or
numbness; Denies tingling or tremor.
Psychiatric: Denies problems with nervousness or depression; Denies lack of interest,
sadness, memory loss, mood changes, or ever hearing voices or seeing things that are
not there.
Physical Exams:
General: Awake, alert, and oriented; No acute distress; Well developed, hydrated and
nourished; Appears to state age.
Skin: Left breast: No palpable masses within tissue surrounding the implant, no
palpable masses, Minor LUE edema from hand to upper arm. Right breast: normal
contour; no skin changes; no nipple changes or discharge; no axillary
