Mrs. C.R. is a 74-year white female presenting with mid to low back pain x 2 weeks. She reports feeling the pain after picking up her 2-year-old great granddaughter while participating in a family garage sale. Pain increases with movement and positioning. Heat and ibuprofen provides no relief. She incidentally reports a noticed “shape change” to her back.
Medical History
- Breast cancer at age 70, treated by doxorubicin chemotherapy and radiation
- Back injury from MVA in 20s
- Hypothyroidism
- GERD
- Frequent UTIs, last infection 2 weeks prior
Medications:
- Levothryoxine
- Omeprazole
Surgical History
- TAH-BSO due to uterine fibroids at age 45 with 2 years of hormone replacement therapy
- Cholecystectomy
- Lumpectomy
Family History
- Mother deceased, history of Parkinson Disease
- Father deceased, history of colon polyps and diabetes
- Brother alive, history of diabetes
- Brother deceased, history of diabetes
- Brother deceases, history of diabetes and stroke
- Brother alive, history of diabetes and COPD
- Sister alive, history of premature menopause, diabetes, and breast cancer at age 78
Social History
- Hobbies include quilting, sewing, and embroidery
Occupational History
- Meat cutter
- Janitor
- Retired