iHuman Week-6 NR-579 Basilia Barco Backpain 53 y/o white female 5’6’’ 165 lb

iHuman Week-6 NR-579 Basilia Barco Backpain 53 y/o white female 5’6’’ 165 lb
Reason for encounter: Back pain
Good:
• How can I help you today? o I’m having terrible back pain. I must have thrown
my back out.
• Do you have any other symptoms or concerns we should discuss? o Right now,
you mean? All I can think about is my back.
• Where more precisely is the pain in your back? o It seems to be in my lower
back.
• When did the pain in your back start?
o Three days ago.
• What are the events surrounding the start of your back pain? o It hit me as I
was lifting a heavy laundry basket full of wet clothes. Wham! Out of nowhere.
• Does anything make the pain in your back better or worse? o It just won’t go
away. I can’t seem to do anything to make it better. It is definitely worse when
I move.
• What does the pain in your back feel like? o It is really sharp, stabbing,
gnawing…
• Does the pain in your back radiate someplace else? Where? o Yeah, I can feel
it in my right leg and sometimes all the way to my foot. It’s not in my foot or
anything, but mostly in my thigh.
• How severe (1-10 scale) is the pain in your back? o It is really excruciating—
10/10 at times.
• Do you have any tingling and/or numbness anywhere? o My right leg feels a
little numb and tingling on the outside of my thigh.
• Are you taking any over-the-counter or herbal medications? o Yes, I’ve been
taking ibuprofen, but it’s not strong enough for this pain.
• ROS: o Fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, or
night sweats?
Yes, a bunch of that. What do you want to know about?
o Do you have any problems with an itchy scalp, skin changes, moles, thinning hair, or
brittle nails? Nope. o Do you have any problems with headaches that don’t go
away with aspirin or Tylenol (acetaminophen), double or blurred vision, difficulty
with night vision, problems hearing, ear pain, sinus problems, chronic sore throats,
or difficulty swallowing?
Nope. o Have you noticed any breast discharge, lumps, scaly nipples,
pain, swelling, or redness?
Everything is totally fine there. Thank the lord.
o Do you experience chest pain discomfort or pressure; pain/pressure/dizziness with
exertion or getting angry; palpitations; decreased exercise tolerance; or blue/cold
fingers and toes? Nope. o Do you experience shortness of breath, wheezing,
difficulty catching your breath, chronic cough, or sputum production?
Not now. o 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?
No. o 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?
Nope. o Have you noticed any bruising, bleeding gums, nose bleeds, or other
sites of increased bleeding?
Nope. o Do you have problems with heat or cold intolerance, increased
thirst, increased sweating, frequent urination, or change in appetite?
My appetite is fine. Not thirsty or cold or peeing too much. o Do you have
problems with dizziness, fainting, spinning room, seizures, weakness, numbness,
tingling, or tremor?
No spinning or passing out or anything like that. Seizures?!? Lord no! What else
did you ask?
o Have you gained or lose weight unintentionally, despite normal appetite and exercise?
Yes actually. I’ve lost about 20 pounds in the last six months without really trying.
Kind of odd.
o Does the pain get better when you ben forward or sit?
Not really. I don’t particularly want to try to bend forward. o
Do you have pain/discomfort when you are at rest?
Yest, it is pretty constant. o
Have you been having fevers?
No fevers or chills.
o Do you have night sweats?
Actually, yes. It’s like starting menopause all over again. What does that have
to do with anything though? Bad:
• Have you had the pain in your back before?
o No, this is something new-and bad.
• What treatments have you had for the pain in your back?

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