Ms. C.S. is a 46-year-old white female, who presents to her primary care physician for further work up after being seen and treated by an orthopedic surgeon for a right distal radius fracture. Patient sustained a low impact fall from standing which led to her injury. She states generally she doesn’t have pain but rates pain in wrist seven out of ten on pain scale.
Pertinent Past Medical and Surgical History
Jones, R. (2013). Distal radius [Picture]. Retrieved from https://emrems.com/2013/10/02/distal-radius/
- Bipolar disorder, diagnosed age 23, medically treated with lithium and cognitive behavior therapy
- Hysterectomy, age 44
- Diabetes type 1, diagnosed age 2
- Depression, diagnosed age 17
Pertinent Social History
- One pack per day smoker since age 17
- Newly divorced after 25 years of marriage
- Has recently been told by primary care physician she is underweight for her height
- Height 5’2 weight 85 pounds
Pertinent Family History
- Father alive at age 76 with history of bipolar disorder
- Mother died of cardiac arrest after a myocardial infarction 60 days post hip replacement at age 66
- Brother alive at age 50 with history of hyperthyroidism
- Sister alive at age 52 with no pertinent medical history