hief Complaints : “My lower back has been hurting for about 2 weeks now”.
History of Present Illness :
Mrs. H is a 26 y/o Hispanic female with a six year history of depression-controlled on Sertraline,
who presents to the clinic today complaining of spontaneous occurring acute low back pain to
lumber region that started about 2 weeks ago after wearing heels to a party. Reports it has
been very difficult to dress lower body and to bend. She reports the pain is constant but has
intermittent intensities of aching and soreness throughout the day. The pain is localized to the
lumber area, described as aching and soreness with no radiation, rated a 5/10 in office today
with 3/10 being the lowest amount of pain experienced and 8/10 being the worst pain she has
experienced. Reports the pain is worse in the mornings when getting out of bed after lying
down all night. She hasn’t tried any pharmacological or non-pharmacological therapies. She
reports no heavy lifting, strenuous exercise, current injuries, nor feelings of anxiety or
depression. However, about 5 years ago she was riding her bike, went down a ramp and flipped
head first over the handle bars of the bike. At which time she experienced this same low back
pain, went to the ER and had X-rays that showed some inflammation and swelling. She was then
prescribed a muscle relaxant, Ibuprofen, and physical therapy for 8 weeks, which helped
tremendously. At today’s visit, she hopes to find out where the pain is coming from and what
she can do to prevent it from returning.
Past Medical History:
• Depression-active- diagnosed 6 years ago after mom passed in a MVA
• Low back pain-active-diagnosed about 5 years ago after previous back injury.
Past Surgical History:
• No surgeries to date
NKA to food, dust, mold, environment, or medications.
Sertraline 150 mg by mouth daily for depression
• Influenza Vaccine-October 2017 at CVS.
• All other immunizations are up-to-date including TDaP, MMR, and Varicella.
• Last Pap smear- June 2016-normal
• Performs MSBE
• Depression screen positive for PHQ2; on meds and see Psychologists regularly.
• CAGE 0/4
Personal & Social History:
• Lives alone in a one bedroom apartment.
• Works at a nursing home as a Certified Nursing Assistant 4 days/week. She loves her job
and has a dependable car.
• Denies any smoking, illicit drug abuse, or alcohol misuse.
• Previously did cross fit in high school. However, do to work she hasn’t had much time to
get the amount of exercise she needs.
• Patient is sexually active with only one sex partner, her boyfriend.
• 24 hour diet recall: B- one bowl of Chex cereal; L- a turkey sandwich, chips, and a diet
coke; S-about 1-2 cups of cheese-it crackers and a diet coke; D- Meatloaf, veggies,
mashed potatoes from Boston Market, and a bottled water.
Paternal: Paternal grandfather 81, HTN, DM; Paternal grandmother 76 history of DM
Maternal: Maternal grandfather died at 82 from MI, maternal grandmother 79, history of
diabetes and arthritis.
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