CC : Back Pain HPI: Jane Anderson is a 48 yr old female who.
CC : Back Pain HPI: Jane Anderson is a 48 yr old female who… CC: Back PainHPI:Jane Anderson is a 48 yr old female who presents to the clinic with a 1 week history of low back pain. She states that she was moving furniture around her house and lifted her couch so that she could vacuum underneath it. She notes that later in the day, she developed lower back pain across her low back. She describes it as sore and achy. The pain does not radiate. She states that her lower back has felt stiff and there are areas of tenderness. She states that she has tried ice, heat, and acetaminophen with some transient improvement. She denies any changes in bowel or bladder control, symptoms of saddle anesthesia. Her significant other has noted that she had some mild swelling after the initial injury but this has now resolved. She is concerned that she needs back surgery.Past Medical HistoryHTNGERDPast Surgical HistoryAppendectomy at age 21Current MedicationsLisinopril 20 mg dailyFamotidine 20 mg dailyAcetaminophen 500 mg twice dailyAllergiesNKDAROSConstitutional: – fevers, chillsHEENT: No changes in vision, no ear drainage. Cardiovascular: No chest pain, palpitations.Respiratory: No shortness of breath or cough.GI: No n/v/abd pain.GU: No dysuria, difficulty voiding.Integumentary: No rashes, wounds.Neuro: – HA, dizziness. No weakness of legs.MS: Low back pain as in HPI. No red or swollen joints.O:Physical ExamVS: T 97.9 P 68 R 16 BP 130/70 O2 sat 98% RAGeneral: Healthy appearing 48 yo woman, appears his stated age. Reliable historian.HEENT: Bilateral ear canals patent. TMs intact and pearly gray with appropriate light reflexes. Nose without drainage. Mouth with moist mucous membranes. Normal dentition. Posterior oropharynx pink and moist.Cardiovascular: S1S2 normal. No murmurs, rubs, or gallops.Respiratory: Lungs clear to auscultation. Respirations even and unlabored.Skin: No rashes on exposed skin.Neuro: DTRs bilateral – achilles 2+, patellar 2+. A&Ox3.MS: Decreased ROM of back. Tenderness on palpation of lumbar spine at the level of L2-L3 and lateral muscles with muscle spasms noted. No swelling, bruising, erythema. Negative straight leg raise test.Extremities: No edema, DP 2+ bilaterally.Labs/Diagnostics 01/2022Creatinine 0.7eGFR >90K+ 4.2 What would you recommend the patient do to treat his back pain initially?A. MS ContinB. Epidural InjectionsC. VenlafaxineD. NSAIDs, PT/OTHealth Science Science Nursing NSG 3871
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