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65 Year-Old African American Female with Severe Fatigue, Cough, Nausea, and Back Pain


65 y/o AAF presents to the office with a severe fatigue, nausea, a productive cough, and low back pain that shoots down the back of the right thigh. The cough started a few days ago but the low back pain has been over the past few months and feels worse when she coughs. She feels nauseated and very tired. Her fatigue has been getting progressively worse over the past month.

ROS: negative except for HOPI
Carpal tunnel syndrome

Meds: Hydrochlorothiazide 25 mg q day
Amlodipine 10 mg daily

Family Hx positive for DM
MI in Father age 62
Mother alive age 91, also with HTN

No surgeries or hospitalizations except for the births of her two children


Social: married, retired teacher, non-smoker, no ETOH
Physical exam
BP 140/92 RR 16 Temp 100.2 Pulse 88
Heent positive for cotton wool spots
Heart RRR s Gallops, Rubs, or Murmurs
Lungs Rales in the LLL
Abd-soft nondistended, BS positive, mild splenomegaly

Neuro pain with palpation over lower back especially over the lumbar spine, neurologically intact
Skin unremarkable
Urinalysis 1 protein
Sputum culture obtained

Labs: CBC, comprehensive metabolic panel, C-reactive protein, ESR, 24-hour urine for total protein, creatinine clearance, chest x-ray, MRI lumbar spine

How would you approach diagnosis and treatment of this patient?