This 40-year-old Latin female presents with complaints of low back and right leg pain. She said that she hurt her back in a motor vehicle accident three years ago and she has had a history of intermittent low back pain since that time. Last December she started a Job where she had to lift boxes that weighed approximately 40 pounds. Around the first of January this year, she began to complain of back pain that gradually went into her right leg.
The pain is primarily in the sacroiliac region and radiates into the buttock and lateral lower leg as far as the ankle. She has no numbness. Coughing and sneezing exacerbates her pain. She has to move around to get comfortable when lying clown, out seen Is more comforts lying down than in any other position. She is still working fulfillment, but is not doing the heavy lifting at this time. She has been going to a Chiropractor for the last two months with no pain relief. She has taken Filler, Norfolk, Ethylene with codeine and Terraced. All of these have failed to improve her symptoms.
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She had a CT scan done gently and we are getting those results. PAST HISTORY: Significant for cesarean section 20 years ago, otherwise negative except as in HIP. ALLERGIES: Some environmental allergies. No known drug allergies. FAMILY HISTORY: The patient was adopted and does not know her family history. She lives with her husband. She has one son living and well, who is in the military. SOCIAL HISTORY: Denies xx. No blood transfusion in the past. PHYSICAL EXAMINATION: This well-developed, well-nourished, thin, pleasant, 40-year- old Latin female is in some distress due to pain. HEN: The patient wears dentures, otherwise normal.
Neck is supple no JIVED. No Lymph– LUNGS are clear MEDICATIONS: Oppression 7. 5 MGM p. O. Daily, astraddle 0. 5 MGM p. O. Cam, Mobil 7. 5 MGM p. O. Daily recently discontinued because of questionable allergic reaction, YACHT 25 MGM p. O. Every other day, and oral calcium supplements, in the past she has been on penicillin, Catherine, and hydrochloride’s but she has not had Euclidean, kaleidoscopically, or calorimetric. ALLERGIES: None by history FAMILY/SOCIAL HISTORY: Noncontributory PHYSICAL EXAMINATION: This is a conically ill appearing female, alert, oriented, and operative.
She moves with great difficulty because of fatigue malaise. VITAL SIGNS: Blood pressure 107/80. Heart rate 100 and regular. Respirations 22. HEN: Unrealistic. No scalp lesions. Dry eyes with conjunctivas injection. Mild expostulates. Dry nasal mucosa. Marked cracking and bleeding of her lips with erosion of the mucosa. She has a large ulceration of the mucosa at the bite margin on the left. She has some scattered ulcerations on her hard and soft palette. She has difficulty opening her mouth because of pain. Tonsils not enlarged. No visible exudates.
SKIN: She has some mild economics on her skin and some rather, she has some patches but no obvious skin breakdown. She had some fissuring in the buttocks crease. PULMONARY: Clear to precession and auscultation, bilaterally. CARDIOVASCULAR: No murmurs or gallops noted. ABDOMEN: Soft, non-tender, protuberant, no organically, and positive bowel sounds. NEUROLOGICAL EXAM: Cranial nerves ii – xii are grossly intact, diffuse hyperplasia. MUSCULAR SKELETAL: Erosive structure changes In elders, wrest, Ana nanas consistent Walt ornamental arthritis. Has had bilateral total knee replacements with stovepipe legs and remedial pitting edema 1+.
I feel no pulse distally in either leg. PHYSICALITY: Patient is a little anxious about these new symptoms and there significance. We discussed her situation and I offered her psychiatric services, she refused for now.