Carlotta A Russe V5 PC Interview

Chief Complaint How can I help you today? Carlotta A Russe V5 PC Interview Do you have any other symptoms or concerns we should discuss? Have you had any trauma to your back? Old carts for HPI What are the events surrounding the start of your back pain? What are the events surrounding the start of the pain in your leg(s)? When did the pain in your back start? Does the pain in your back radiate someplace else? Where? Where more precisely is the pain in your leg(s)? Where more precisely is the pain in your back? Does the pain in your back come and go? What does the pain in your back feel like? Do you have pain when lifting? Does anything make the pain in your back better or worse? How severe (1-10 Scale) is the pain in your back? PMH, FH, SH as Needed Any new or recent change in medications? Are you taking any over the counter or herbal medications? Do you have any allergies? Review of Systems (ROS) Do you have problems with heat or cold intolerance, increased thirst, increased sweating, frequent urination, or change in appetite? Do you have problems with dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, or tremor? Do you have problems with fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, or night sweats? When you urinate, have you noticed any pain, burning, blood, difficulty, starting or stopping, dribbling, incontinence, urgency during day or night, or any changes in frequency? Do you have any problems with headaches that don’t go away with aspirin or Tylenol (acetaminophen), double or blurred vision, problems hearing, ear pain, sinus problems, chronic sore throats, or difficulty swallowing? Do you have problems with nausea, vomiting, constipation, diarrhea, coffee grounds in your vomit, dark tarry stool. Bright red blood in your bowel movements, early satiety, or bloating? Assessment Vitals: Temperature, Pulse, Respiration, BP, Mental Status Breast: Breast Exam Heart: Auscultate heart Chest wall & Lungs: Auscultate lungs Abdomen: Palpate Abdomen Musculoskeletal: Inspect/palpate back and spine, test range of motion, test strength Neurological: Assess gait & stance, Reflexes: Deep tendon and Plantar/Babinski (L5/S1), Sensory tests Key Findings Acute onset LBP radiating down right leg following lifting tables: MSAP RLE sensory deficit: RELATED RLE motor deficit: RELATED Hyporeflexia: right patellar tendon: RELATED Positive right straight leg raising (SLR) test; positive contralateral SLR: RELATED Asthma: UNRELATED Hypertension: UNRELATED Osteoporosis: UNKNOWN Postmenopausal status: total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH BSO): UNKNOWN 40 pack year history of smoking: UNKNOWN History of systemic steroid use: UNKNOWN Problem statement Ms. Russe is 65 year old female who presents with the acute onset of LBP (scale 7/10) 2 days ago following the moving of heavy tables at work. The pain starts in her back and radiates down her right leg impairing both gait and sleep. Physical examination demonstrates positive straight leg raise on both R with positive finding with contralateral leg raise, RLE sensory, motor and reflex deficits. She denies fevers/chills/night sweats, bladder/bowel dysfunction and denies unintentional weight loss. Significant PMH is her osteoporosis, 40 pack year smoking history and history of steroid use. Systems Affected Respiratory, Neurological, and Musculoskeletal Diagnosis Carlotta diagnosis is Disk herniation. Differential diagnosis is : Spinal neoplasm and Compression fracture. Plan Prescribe Analgesics: NSAIDS or acetaminophen, or narcotics if pain is refractory and only for short term use. Refer to physical therapy Consider epidural steroids injections Monitor longitudinally for surgical indications