2-3 PATIENT NOTE: BACK PAIN HISTORY: Describe the history you just obtained from this patient.

Include only information (pertinent positives and negatives) relevant to this patients problem(s). HPI: 46 YO MALE C/O LOWER BACK PAIN, STRTED 2 WEEKS AGO WHILE MOVING FURNITURE. PATIENT REPORTS INTERMITTEN BACK PAIN FOR MANY YEARS, THIS EPISODE IS THE MOST EXTREME. ITS BURMING AND POUNDING, 8/10 INTENSITY. CONSTANT, NON-PROGRESSIVE AGGRAVATED BY WALKING OR GETTING UP FROM A CHAIR, LIFTING, TWISTING OR BENDING ALLEVIATED BY REST AND LEANING FORWARD PATIENT REPORTS DIFFICULTY URINATING, BURNING UPON URINATION, DECREASED STREAM, INCOMPLETE EMPTYING, NO BOWEL CHANGES, NO DISCHARGE, NO ABDOMINAL PAIN NO INCONTINENCE. ROS: NEGATIVE EXCEPT AS NOTED ABOVE ALLERGIES: PENICILLIN CAUSE URTICARIA MEDICATIONS: HYDROCHLOROTHIAZIDE, TYLENOL PMH: DIANOSED WITH HYPERTENSION FIVE YEARS AGO, CONTROLLED WITH MEDICATION PHS: NONE FH: FATHER IS HOSPITALIZED WITH ALZHEIMERS, MOTHER IS ALIVE AND WELL SH: SMOKES 1PPD FOR TEN YEARS, ETOH ON THE WEEKENDS, CAGE 0/4, DENIES DRUG USE, WORKS IN CONSTRUCTION, LIVES WITH TWO DOGS. SEXUALLY ACTIVE WITH THE SAME GIRLFRIEND FOR FIVE YEARS USES CONDOMS. PHYSICAL EXAM: Describe any positive and negative findings relevant to this patients problem(s). Be careful to include only those parts of examination you performed in this encounter. HE IS ANXIOUS TO LEAVE TO CARE FOR HIS DOGS. HIS VITALS ARE WITHIN NORMAL LIMITS. HIS BREATH SOUNDS ARE CLEAR BILATERALLY. HIS HEART SOUNDS ARE NORMAL WITH NO RUBS, GALLOPS OR MURMURS. HE BACK IS TENDER AT THE LUMBAR SPINAL PROCESS. HIS CERVICAL AND THORACIC SPINAL PROCESSES ARE WNL. HE SHOWS MILD CVA TENDERNESS B/L. THERE IS TENDERNESS ON PALPATION AT THE LUMBAR PARASPINAL MUSCLES AS WELL AS A POSITIVE STRAIGHT LEG RAISE TEST. HIS RANGE OF MOTION IS WNL TO FLEXION, EXTENSION AND SIDE TO SIDE. HIS BENDING AND GAIT ARE NORMAL. HIS MUSCLE STRENGTH IS 5/5 B/L AND HE HAS INTACT SENSATION TO DULL AND SHARP BILATERALLY. ACHILLES AND PATELLAR REFLEXES ARE 2/4 BILATERALLY. PULSES ARE NORMAL BILATERALLY. DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patients complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if

any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc. Diagnosis #1: MUSCLE STRAIN HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) - C/o back pain associated with mechanical - Patient is anxious to leave Trauma -Aggravated by walking and lifting objects, - Point tenderness in the lumbar alleviated with rest spine, tender paraspinal muscles -H/o intermittent back pain present for years - Positive straight leg raise test Diagnosis #2: HERNIATED DISC HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) - H/o trauma to back while moving - Point tenderness in the lumbar furniture 2 weeks ago spine and paraspinal muscles - Aggravated by walking and lifting objects, - B/L CVA tenderness alleviated with rest -C/o difficulty urinating, burning urination, - Positive straight leg raise test decreased stream and incomplete emptying Diagnosis #3: LUMBAR SPINAL STENOSIS HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) - Back pain is aggravated on walking, - Point tenderness in the lumbar lifting objects, alleviated with rest spine and paraspinal muscles - H/o trauma to back while moving furniture - B/L CVA tenderness 2 weeks ago -C/o difficulty urinating, burning urination, - Positive straight leg raise test decreased stream and incomplete emptying Diagnostic Studies: - RECTAL EXAM - XR-L-SPINE - MRI-L-SPINE - PSA - CBC/UA