IHUMAN Case # 5

Case: Sam Newton Date: April 4, 2021 CC: 62 y/o M Chief complaint is a short 1-2 statement or word phrase from patient and should be listed in “quotes” “My back is killing me. … it is so bad I can’t think about anything else.” HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts Mr. Newton is a 62-year-old mal patient presenting to the clinic with complaint of acute onset lower back pain of 11/10 intensity. He describes the quality of the pain as sharp, stabbing that radiate to the back of lower extremities with the right side the most uncomfortable. Patient has history of significant moderate intensity chronic lower back pain for 2-3 months. He has a history of high blood pressure and BPH for which he has stopped taking medication he also has history of hepatitis C. He reports that he has not seen a doctor in years. Family medical history is unremarkable. He has a history if intravenous drug use, and cigarette smoking. Onset: Severe lower back pain that started today; moderate mid-back pain for 2- 3 months Location: Mild pain in middle of back; severe pain in lower back pain (L1-3) that radiates to back of legs and more intense in right lower extremity. Duration: Moderate mid-back pain is intermittent. Severe lower back pain has persisted since onset in the morning. Character: Sharp and stabbing pain that is getting worse Aggravating/alleviating factors: Pain gets worse when standing or moving around and unresolved with Tylenol and NSAIDs. Nothing has helped with pain Related symptoms: Pins and needles in the butt area Treatments: Has tried OTC analgesics; Tylenol and Motrin without relief Significance: Pain in mid-back has severity of 3-4 on scale of 1-10 and the lower back pain is as severe as 11/10. Patient cannot walk or cannot think of anything else Case: Sam Newton Date: April 4, 2021 PMHx child/adult illness/hospitalizations/immunizations  No serious childhood illnesses except for common colds, coughs, and stomach pain  Benign prostatic hyperplasia, high blood pressure, hepatitis C.  No hospitalization SurgHx type/when/why/complications  No surgical history FamHx Grandparents (if known)/Parents/siblings/children  No history on grandparents  Both parents were healthy and died from old age  No children SHx Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships  Smoked a pack of cigarette a day for 30 years but quit 5 years ago  History of intravenous drug use (Heroin); he has been clean for 30 years  He has down on alcohol consumption; He used to take 4-5 beers a day, but he has cut down.  Patient works as a environmental cleaning car driver Reproductive Hx Female: Age of menarche/menstruation cycle duration/gravida para status/Childbirth hx/sexual hx and concerns/LMP/menopause Breast/cervical screening (if any) Male: Sexual hx and concerns/issues with fertility (if any)/Testicular or prostate screening (if applicable) Screening for STI’s (if applicable)  Patient refused to answer question about STDs  He reports he is heterosexual Allergies (Food, Drug, Environmental, etc.)  NKA List of Medications/supplements (prescription, OTC, complementary alternative therapies)  Tamsulosin (Stopped taking it 5 years ago)  BP medication (Stopped taking it 5 years ago)  Tylenol  Motrin