Description
OF PRESENT ILLNESS: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of LOWER BACK PAIN 3 days ago. She noticed the pain about a 3days ago after lifting a box and tweaked her. back. She states that she experiences constant pain. Pain is a 5/10 and is located in her lower back and not radiating. Takes Advil to make pain better but pain hinders her from doing her usual daily activities.
Social History: She denies any specific changes in her diet recently. She denies use of tobacco and illicit drugs. She drinks alcohol occasionally. She does not exercise.
Review of Systems: General: Denies changes in weight and general fatigue. She denies fevers, chills, and night sweats. •
Cardiac: Denies a diagnosis of hypertension, but states that she has been told her blood pressure was high in the past. She denies known history of murmurs, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema. •
Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16. •
Gastrointestinal: States that in general her appetite is unchanged, although she does note that she will occasionally experience loss of appetite in anticipation of the pain associated with eating.
Denies nausea, vomiting, diarrhea, and constipation. Bowel movements are daily and generally brown in color. Denies any change in stool color, consistency, or frequency. Denies blood in stool, dark stools, or maroon stools. No blood in emesis. No known jaundice, problems with liver or spleen.
MUSKOSKELETAL: Performed range motion in all extremities with no abnormalities noted.
DIAGNOSIS: LOWER BACK PAIN.
NOTE:USE THE ATTACHED TEMPLATE TO ADDRESS THIS SCENARIO.
Individual Project Case Presentation Template
(Based on Shadow Health Assignment)
Identified case title:
Significant history findings: Note findings acquired from Shadow Health case.
Pertinent physical exam findings: Note findings acquired from Shadow Health case.
Differential diagnosis: Select a minimum of 3 medical diagnoses.
Diagnostics: List what diagnostic exams would be used to obtain a diagnosis.
Final diagnosis: Provide medical diagnosis with supporting rationale for chosen diagnosis.
Pathophysiology of diagnosis: Describe the process that occurs within the body for the diagnosed disease.
Treatment plan: Include pharmacological treatment with patient education.
NOTE: Must utilize a minimum of 3 references with one being UpToDate®.
