M.P. a 60 year-old Caucasian femaleLast 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 51Hx of HTN; hypercholesterolemia, bronchitis, bladder prolapse and stress incontinence.Current MedicationsQuinipril/HCTZ 20/12.5 mg dailySimvastatin/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 SpringSmoker 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 yearsImmunizations (Flu vaccine yearly; Tetanus 7 years ago; denies ever having the Pneumococcal Vaccine or Herpes Zoster vaccine)FH:
Father: age 87; HTN; skin cancerMother: deceased age 79; HTN; DM Type 2; Osteoporosis2 sisters – 1 alive & well age 65; 1 deceased at age 58 – breast cancer3 adult children alive and wellSH:Currently works as an Administrative Assistant at the local Middle School.Married 35 years; 3 children and 1 grandchildLives 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 dailyNo exercise routine. Sedentary lifestyleROS: Pertinent Negatives
Denies headache, dizziness, fainting, vision change, blurred vision, eye pain.Denies chest pain/pressure, SOBDenies chest pressure or palpitationsDenies weakness, numbness, tingling of extremitiesROS: Pertinent Positives
Severe diffuse pain in upper and lower backUnable to lift packages, children or any type of weight-bearingAssessment 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 132/72Heart : No gallop, murmur or rub, RRRLungs: 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 ROMCVA 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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