B.P. is a 68-year-old pleasant white female. She has been experiencing significant back pain for several weeks. She has been taking OTC Ibuprofen PRN for pain with temporary relief but states the pain is otherwise constant. She said exercise aggravates the pain. She denies any acute injury to her back but states she had COVID-19 with a prolonged and severe cough approximately 1 month ago. She states she a history of a vertebral fracture at T10 5 years ago.
B.P. loves to garden and work in her yard. She states that she has had to take care of her ailing husband for the last year. She states they live in their own home, and that she was still able to take care of household chores and work in her yard until her back pain began.
B.P. states she started menopause at age 51 and has never needed hormone replacement. She states she still has mild hot flashes and vaginal dryness. She states she was 63 when she had a vertebral facture at T10 that occurred when she was carrying a gallon of milk into the house. She states at the time the DEXA scan put her in the osteopenic category. She has a history of seizures but states that her seizures are controlled with medications and that she has not had a seizure in over 20 years. She states she also has a history of asthma since childhood, however she only needs a rescue inhaler PRN and has not had to use the inhaler in 6 months for her asthma. She states that even though she has been taking her calcium she has noticed a height reduction in the last several years.
The patient states her older sister has osteoporosis and has had a hip fracture. She states her maternal aunt also had osteoporosis and had a wrist fracture. B. P.’s mother was diagnosed with breast CA at age 57 and died from pancreatic cancer at age 67. She reports her father died at age 89 from an MI. She states her younger brother had HTN.
B.P. states she has smoked 5 cigarettes a day for the last 5 years but cut down from an entire pack a day for 40+ years. She states she would like to quit but believes that this is not a good time in her life with the stress she is experiencing. She reports she drinks 1-2 glasses of wine per day. Her main intake of calcium is the milk that she has with her cereal daily. She also states she has cheese a couple of times a week. She states that she does very little weight bearing exercises. She states that she always applies sunscreen before going in the sun.
B. P. denies any unusual bleeding, weakness, back spasms, shortness of breath, chest pain, fever, chills, heat or cold intolerance and changes in hair skin or nails. She reports vaginal dryness, occasional hot flashes, and night sweats.
Current Medications – Calcium Carbonate 1.25 g PO BID – takes occasionally
Multivitamin 1 PO QD
Albuterol MDI 2 puffs BID PRN
Allergies – Codeine – nausea and vomiting
Sulfa – Rash
Aspirin – Hives and wheezing
Vital Signs – 130/80; Pulse – 88; Respirations – 20; Temperature – 98.4 F. Ht 5’4” Wt 102 lbs.
Physical Exam – General – Alert and Oriented X 3, pleasant cooperative 68-year-old white female who walks with a normal gate and is no apparent distress. She appears anxious currently. Skin – Fair complexion. Turgor good. No lesions. Head – Normocephalic; Eyes – PERRLA, unremarkable exam; Ears – TM intact and pearly bilaterally. Throat – Mucous membranes moist and without drainage. Neck – supple, Thyroid – non tender without masses, no JVD, full range of motion without pain. Chest – equal chest expansion bilaterally, clear to auscultation bilaterally; Cardiac – regular rate and rhythm, no murmurs, S1 and S2 present; Abdomen – Soft and nontender, bowel sounds positive in all 4 quadrants, no masses noted; Musculoskeletal- All peripheral pulses 2 +, tenderness to palpation at L2. Limited flexion and extension of the back, significant lumbar lordosis. Later bend – full range of motion and nontender, Negative for kyphosis, negative for deformity or swelling of the joints. Neurologic – Memory intact, cranial nerves intact, no motor deficits or cross sensory deficits; Toes down going.
Laboratory test findings
Na – 135 meq/L (normal 135-145)
K – 4.2 meq/L (normal 3.5-5.0)
Ca – 8.8 mg/dL (normal 8.5-10.5)
Mg – 1.9 mg/dL (normal 1.8-3.0)
PO4 – 4.8 mg/dL (normal 2.5-4.5)
HCO3 – 25 meq/L (normal 22-32)
Cl – 105 meq/L (normal 101-112)
25, OH Vitamin D 3 ng/mL (10-50 normal )
DEXA Scan Results
Lumbar Spine – -3.79
Right Femoral Neck – -3.19
Right Radius – -2.97
