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Mary Hotch
54-year-old female
Entered Clinic with her husband
Walking…
Mary Hotch
54-year-old female
Entered Clinic with her husband
Walking Cautiously
Complains of Sharp pain in back and legs
Pain associated with numbness and tingling
More pain in left leg
Recently had a slip and fall on ice
Has experienced pain since
Went to a new restaurant in the last week where she later experienced loose stools accompanied by pain, fever, chills, and vomiting. She claims it has cleared up on its own.
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Family History
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Youngest daughter suffered from leukemia at the age of 4 and was deemed cancer free at the age of 10
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Social History
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No history of smoking, though father smoked around her as she grew up
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REVIEW OF SYSTEMS
Skin
scrape on hand and back from fall on ice, not inflamed or showing signs of infection
Neuro
had a recent fall - experiencing sharp pain in back and legs accompanied with tingling and numbness in her left leg, has not gone away. Has been feeling more tired and worn out easier due to extra exertion to walk carefully.
Heart
no palpitations, irregular heart rhythms, or chest discomfort
Lungs
no trouble breathing, rales, or crackles
Abdomen
no pain currently, but there was discomfort upon palpation when she was experiencing GI distress
Urinary
no issues with urination, incontinence, etc.
Reproductive
post menopause, no issues
GI
GI distress after eating at a restaurant. Loose stools, nausea and vomiting, but it cleared up on its own after 24 hours.
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Possible Diagnosis
Musculoskeletal
Spondylosis
affects discs in the spine, may cause similar symptoms such as back pain
Rheumatoid Arthritis
she is of older age, experiencing more fatigue and tiredness in activates she’s always done
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Myeloma
people over age of 50 usually affected, pain in the back and fatigue
Osteoporosis
back pain, could be in earlier stages in her age
Gastrointestinal
Food Poisoning
more common in older adults, can cause problems that result in damage
to kidneys which can cause back pain
Irritable Bowel Syndrome
can cause lower back pain, recent issues with bowel movements
Colon Cancer
diarrhea, fatigue, can also cause back pain
Neruo
Spinal Stenosis
back pain, numbness and tingling in lower extremities
Sciatica
pain radiating from back and to legs, numbness, tingling in the thigh
Reproductive
UTI
experienced UTI in the past, causes lower back pain and may have spread up to the kidneys
Ovarian Cysts
nausea and vomiting, fever, painful bowel movements
Pulmonary
Lung Cancer
grew up around secondhand smoke, cancer could have possibly spread to spine hence the back pain
Circulatory/Cardiac
Aneurysm
weak spot in aorta can cause back pain, hypertension
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