Left Lower Back Pain Case Study

CC

Ms. Beevers is a 69-year-old female here today complaining of left lower back pain.

HPI

The patient tells me this pain started just a couple of days ago on Wednesday evening. She said that it started in the left side of her back. Since then, it seems to move around the side and into her left lower abdomen, pelvis area, and right over the bladder where she feels a lot of pressure and pain. She has a history of sciatica on the left side and initially thought this just might be her sciatica type pain. However, the fact that it has radiated to the front is very different from the sciatica pain she has had in the past, which is what prompted her to seek care. When it initially happened, she was feeling nausea, but that has resolved. She

She has had no gross hematuria. She tells me that her stools are normal. There is no constipation or diarrhea. There does not seem to be any change in her pain in her back or her pelvic area when she has a bowel movement. There have been no fevers. She has had no body aches or chills and has otherwise been feeling okay. She does have a history of prior abdominal surgeries. She has had a hysterectomy with one ovary removed. She is not sure which ovary she still has remaining. She has also had a laparoscopic cholecystectomy in the past, as well. No history of kidney stones to her knowledge. She does have known diverticulosis based on her 2011 colonoscopy. She does not recall having pain like this in the past before. She has been using Advil, which she says does help some, but she thinks she is taking too much of it. She is using two or three tablets every three to four hours to help her with her

We did talk about options. At this point, I have a urine culture pending, though without the other typical symptoms, makes that less likely. We reviewed other differential diagnostic considerations, including the fact of diverticulitis. She had some mild tenderness there, but certainly having no guarding or rigidity and a fairly benign exam. However, with this being a Friday afternoon and the weekend coming up, I felt it was prudent to move forward with a CT. She was given an order for that. She knows that we will contact her with the results of that testing. In the meantime, review of the other differential diagnoses, including the fact that this could be musculoskeletal was unknown to her. She will monitor her symptoms closely. She was told in no uncertain terms that if her symptoms worsen acutely, worsening back pain, belly pain, nausea, vomiting, high fevers, or other concerns, she is to seek care immediately at the ER to have the evaluation happen more quickly. She was comfortable with that. She was given Cipro 500 mg one p.o. twice daily #14 with no refills. She knows to start that and we will contact her with the results of her testing. We may need to add additional medication, depending on the results. In addition, was given Vicodin 5/300 mg one to two every eight hours p.r.n. #15 with no refills. I reviewed the use