I human Documentation_Note_3 for Beatrice Barlow complete

Beatrice Barlow 53 Y/O female Subjective CC: “I am having terrible back pain; I must have thrown my back out” HPI: Beatrice Barlow is a 53 y/o female that presents to the clinic for evaluation of bilateral lower back pain that is severe 10/10, sharp, and constant. The pain started 3 days ago after lifting a laundry basket full of wet clothes. She reports that the pain radiates down her RLE to her foot. She denies a history of any trauma, and states that she cannot perform daily activities due to the pain. Onset: 3 days Characteristics: stabbing, gnawing Aggravating/Alleviating: aggravating with movement, mildly alleviated with ibuprofen to 8/10 pain Relieving: Ibuprofen Treatments: None Timing: constant Severity: 10/10 PMH: HTN for 9 years ago well controlled, left mastectomy 5 years ago with radiation and chemotherapy treatment for intraductal carcinoma, menarche at 10 y/o, menopause at 48 y/o after chemotherapy, G2P2- first pregnancy at 33, tubal ligation at 40. Allergies: none Medication: OTC Ibuprofen, HCTZ for BP (dosage needed) Surgeries: mastectomy 5 years ago, tubal ligation 13 years ago OB: G2P2 Health Maintenance: Should have gotten information FH: Children: Alive and healthy Mother: Died at 55 of breast cancer, metastatic disease Dad: Unknown MGM: Unknown MGF: Unknown PGM: Unknown PGF: Unknown SH: Elementary school principal, married 27 years, 2 daughters age 18 and 20, EtOH: rare (What is rare? Can be very different from person to person) Caffeine: minimal (same as above) Smoker: Never .............................................continued...........................................................