Family Medicine H and P 3

History

Identifying Data:

Full Name: RT

Date: 9/24/2019

Address: Jamaica, Queens

Age: 49

Location: Amazing Medical clinic

Marital Status: married

Source of Information: Self

Source of Referral: Self

Chief Complaint: “ I’ve been having back pain for the past 4 weeks”

HPI:

49 year old obese male, with PMHx of  HTN, DM2, asthma, presents to the clinic with c/o lower back pain x 4 weeks. Pt claims the back pain started when he was driving home from his sons home in New jersey 4 weeks ago. He has had two other visits in the past 4 weeks for the same compliant. Pain is aching, localized to the lower lumbar region, intermittent, 5/10 in intensity, and does not radiate. Patient states the pain is better when he is lying down or walking, but worse with sitting. Pt has been taking ibuprofen 600 mg as needed with minimal relief. Pt states he was sent out for X-ray of the back a week ago which showed no abnormalities. Pt is still concerned and wants to be sent out for an MRI. Denies any family hx of cancers, trauma/fall, saddle anesthesia, numbness/tingling, fevers, weight loss, CP, SOB, abdominal pain, bowel or urinary incontinence, or heavy weight lifting.

DDX:

Back strain

Acute disc herniation

Osteoarthritis

Spinal stenosis

Fracture

Past Medical History:

Past medical illnesses

HTN x  10 years- well controlled with medication (Amilodipine and Hydrochlorothiazide)

Asthma- well controlled has not used rescue inhaler x 2 years

DM2 x 5 years -well controlled with medication( Metformin 500mg once a day and life-style modifications

Childhood illnesses – Chicken pox at age 7. Denies other illnesses.

Immunizations – Up to date; flu vaccine yearly.

Screening tests and results – Screening colonoscopy 2017, benign.

 

Past Surgical History:

none

Medications:

Metformin 500 mg once a day for DM

Albuterol 90mcg as needed for Asthma

Ibuprofen – 600 mg as needed for back pain

Amlodipine 5 mg one tab once a day

Hydrochlorothiazide 12.5  one tab once a day

Allergies:

Denies drug, environmental or food allergies.

Family History:

Paternal Grandfather – pt doesn’t know

Paternal Grandmother – pt doesn’t know

Maternal Grandfather – pt doesn’t know

Maternal Grandmother – pt doesn’t know

Father – deceased at 75, heart attack

Mother –  80 alive and well

Daughter – 35, alive and well

Daughter – 36, alive and well

Denies family h/o heart arrhythmia, heart disease, lung disease, CVA, cancer, diabetes mellitus, allergies, asthma, gastrointestinal disease, disease of the urinary tract, or psychiatric or nervous disorders.

Social History:

Mr.  is a married male, living with his wife. He is currently unemployed

Habits – He drinks about 1-2 cups of caffeine daily. Denies drinking alcohol, smoking cigarettes, smoking cigars, or illicit drug use.

Travel – He denies any recent travel.

Diet – He follows a diet to decrease his blood sugar due to pre diabetes, mostly consuming chicken, salmon and vegetables.

Exercise – He walks 2 miles 2- 3 times a week, but  has not been able to walk more than 1 mile for the past week due to lower back pain.  He sleeps about 8 hours each night.

Safety measures – admits to wearing a seat belt.

Sexual hx – he is currently sexually active with 1 partner, his wife. He uses condoms as contraception. Denies h/o STIs.

ROS:

General – denies recent weight loss or gain, loss of appetite, generalized weakness/fatigue, fever or chills, or night sweats.

Skin, hair and nails – denies change in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution.

Head – denies headaches, vertigo, head trauma.

Eyes – wears glasses; denies visual disturbance, lacrimation, photophobia, pruritus; LT eye cataract surgery in 2017, no complications.

Ears – denies deafness, pain, discharge, tinnitus, or use of hearing aids.

Nose/Sinuses – states that he has chronic nasal congestion due to deviated septum; denies discharge, epistaxis or obstruction.

Mouth and throat – states that he has 2 dental bridges; denies bleeding gums, sore tongue, sore throat, mouth ulcers, or voice changes. Last dental exam was 3 years ago.

Neck – denies localized swelling/lumps, stiffness/decreased range of motion.

Breast – denies lumps or pain.

Pulmonary System – h/o of asthma stable has not used inhaler in 2 years.. denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea or PND.

Cardiovascular System –  h/o HTN x 10 yrs. Denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur.

Gastrointestinal System – denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructations, abdominal pain, diarrhea, change in bowel habit, hemorrhoids, constipation or melena.

Genitourinary System – states that he has urinary urgency, urinary frequency and nocturia; denies flank pain, oliguria, polyuria, dysuria, incontinence, hesitancy or dribbling. He doesn’t know when he had his last prostate exam.

Nervous System – denies seizures, headache, loss of consciousness, sensory disturbances, numbness/tingling, ataxia, loss of strength, change in cognition/mental status/memory, weakness.

Musculoskeletal System – ℅  lower back pain x 7 weeks; denies deformity/swelling, redness

Peripheral Vascular System – denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, color change.

Hematologic System – blood transfusion at age 61 during the cervical anterior laminectomy; denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.

Endocrine System –  h/o  DM (well controlled on Metformin). denies polyuria/polydipsia/polyphagia, heat or cold intolerance, goiter, excessive sweating, hirsutism.

Psychiatric – denies depression/sadness, anxiety, obsessive/compulsive disorder, seeing a mental health professional, taking psychiatric medications.

Physical

General:  y/o male, AO x3. Patient is well developed, and well groomed. He looks his stated age appears to be in no acute distress.

Vital Signs:

BP: 128/80

RR: 16 breaths/min, unlabored

HR: 70 beats/min, regular

Temp: 98.6 T (oral)

O2 Sat: 98%, room air

Height: 66 inches

Weight: 190 lbs

BMI: 30.7

Labs:

ESR: 10

CBC-WNL

Imaging done during last visit 9/10/2019

X-ray  lumbar spine 4 views  – findings: no evidence of fracture, spondylosis, or spondylolisthesis. No hypertrophic degenerative changes. No scoliosis.

Skin: warm & moist, good turgor. Non-icteric, no cyanosis no lesions noted, 6 inch linear scar noted on the lower abdomen, no tattoos.

Hair: average quantity, and distribution.

Nails: no clubbing, capillary refill <2 seconds throughout.

Head: normocephalic, atraumatic, non-tender to palpation throughout.

ENT: nose patent, mucosa pink and moist, oropharynx clear, Auditory acuity intact to whispered voice AU.

EYES: PERRLA, EOMI, anicteric, no erythema, no discharge

Cardiology: normal S1 and S2, no murmurs or extra heart sounds, noted on auscultation carotid pulses are 2+B/L no bruit noted, no JVD noted.

Respiratory: chest non-tender to palpation, Lat to AP diameter 2:1 with symmetrical rise, Respirations unlabored/no use of accessory muscles noted no evidence of trauma, no rales, crackles wheezing, or rhonchi noted on exam.

Gastroenterology: distended abdomen, tender to palpation throughout, hypoactive bowel sounds, no Guarding, no Rebound, neg rovsings.

Musculoskeletal: FROM upper and lower extremities, limited lumbar/hip flexion, mild discomfort/pain on lumbar/hip flexion. no swelling, deformity, or erythema, no tenderness on palpation, normal gait, Straight leg test neg.

Neurology: A&O x3, no focal neuro deficit. normal strength, sensory intact

Neck: Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no palpable adenopathy noted.

Thyroid: Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Rectal and Genital exam not performed patient refused.

Assessment:

49 year old obese male, with PMHx of  HTN, DM2, asthma ( all well controlled) presents to the clinic with c/o lower back pain x 4 weeks. This is his third visit to the clinic for the same compliant. Pain is localized to the lower lumbar region, intermittent, 5/10 in intensity, and does not radiate. Pain is better when he is lying down or walking, but worse with sitting. Pt has been taking ibuprofen 600 mg with minimal relief. X-ray of the back obtained showed no abnormalities. On exam patient has mild discomfort and limited ROM on flexion of the lumbar/hip. Patient’s history and physical, absence of red flags, absence of signs of systemic disease or cancer, does not warrant an MRI at this time. Patient may benefit from the addition of a muscle relaxant to his treatment plan.

Plan:

Back pain

Prescribe –Cyclobenzaprine 5 mg 3 times daily

Continue to take Ibuprofen 600 mg up to four times daily as needed

Advise patient to returning to their usual activities, and avoid prolonged bed rest.

Educate patient on benefits of weight loss on back pain.

Educate on the patient on the indications for MRI

F/U in two weeks earlier if symptoms get worse.

 Patient information:

Low back pain (LBP) is defined as acute (less than 4 weeks), subacute (4 to 12 weeks) or chronic (more than 12 weeks) according to the duration of symptoms.

Most patients with acute low back pain improve regardless of specific management.

Today we are adding a muscle relaxant to your treatment. You are to take this muscle relaxant along with the NSAID this is called combination therapy.

Self care is an important part of back pain resolution. Avoid bed rest, since studies indicate that bed rest does not in- crease the speed of recovery and in fact may delay it.Try your best to continue with your usual daily activities.

Walking and aerobic exercise has been reported to improve or prevent back pain.

Weight loss is also an important factor in helping decrease your back pain.

Excess weight, has a direct effect on the likelihood of developing low back pain, as well as an adverse effect on recovery.