Case # 1
Patient Information:
Initials B.S., Age 42, Sex M, Race W
S.
CC Back pain radiating down left leg
HPI: B.S., a 42-year-old White Male
Location: low back, left leg
Onset: intermittent one month
Character: aching back pain, sharp shooting pain down left leg
Associated signs and symptoms: shooting pain in leg intermittent, acute episodes
aggravated by standing and walking.
Timing: after sitting for extended period of time driving trucks.
Exacerbating/ relieving factors: Standing up walking after sitting aggravates pain, warm
baths and ice pack provided mild relief.
Severity: 7/10 pain scale
Current Medications: Sildenaphil 50 mg PO 60 minutes prior to sexual activity PRN ED
Allergies: NKDA
PMHx: Refuses flu vaccine. Appendectomy 2012, umbilical hernia repair 2015.
Soc Hx: Long distance truck driver. Smoke > 4 cigarettes daily, drinks one bear nightly, denies
illicit drug use, heterosexual, married 5 years. Denies history of sexually transmitted infection.
Wears seat belt, sits for long hours while driving, places wallet in back left pocket.
Fam Hx: Pt was adopted unknown family HX, two living children, no known health problems.
ROS:
GENERAL: Denies unintended weight loss or gain. Denies fever, malaise, swollen glands,
cough, N/D/V.
This study source was downloaded by 100000840858457 from CourseHero.com on 04-21-2022 17:01:00 GMT -05:00
https://www.coursehero.com/file/27368490/week-8-discussion-nurs-6512docx/
Patient Information:
Initials B.S., Age 42, Sex M, Race W
S.
CC Back pain radiating down left leg
HPI: B.S., a 42-year-old White Male
Location: low back, left leg
Onset: intermittent one month
Character: aching back pain, sharp shooting pain down left leg
Associated signs and symptoms: shooting pain in leg intermittent, acute episodes
aggravated by standing and walking.
Timing: after sitting for extended period of time driving trucks.
Exacerbating/ relieving factors: Standing up walking after sitting aggravates pain, warm
baths and ice pack provided mild relief.
Severity: 7/10 pain scale
Current Medications: Sildenaphil 50 mg PO 60 minutes prior to sexual activity PRN ED
Allergies: NKDA
PMHx: Refuses flu vaccine. Appendectomy 2012, umbilical hernia repair 2015.
Soc Hx: Long distance truck driver. Smoke > 4 cigarettes daily, drinks one bear nightly, denies
illicit drug use, heterosexual, married 5 years. Denies history of sexually transmitted infection.
Wears seat belt, sits for long hours while driving, places wallet in back left pocket.
Fam Hx: Pt was adopted unknown family HX, two living children, no known health problems.
ROS:
GENERAL: Denies unintended weight loss or gain. Denies fever, malaise, swollen glands,
cough, N/D/V.
This study source was downloaded by 100000840858457 from CourseHero.com on 04-21-2022 17:01:00 GMT -05:00
https://www.coursehero.com/file/27368490/week-8-discussion-nurs-6512docx/
