Review of Case 1: Back Pain
Patient Name: J.O. Age: 42 Sex: Male
Race: Caucasian
S.
CC: “pain in lower back”
HPI: J.O., a 42-year-old Caucasian male, presents to the clinic due to reports of pain in his lower
back that started about one month ago. He describes the pain as sharp and shooting pain that
sometimes radiates to his left leg. He denies associated symptoms and states that it seems to
happen intermittently throughout the day, depending on his activity. He reports that it worsens
after he has been on his feet or walking around for a long time. He states that it improves some
when he lays or sits down to rest. 800mg of ibuprofen every eight hours makes the pain
tolerable, and his pain rating is an 8/10 on the pain scale. He has tried applying ice and heat,
which slightly alleviates the pain. There has been no known recent injury.
Current Medications:
Pantoprazole 40mg once daily for GERD- started one year ago.
Lisinopril 10mg once daily for HTN- started two years ago.
Osteo Bi-Flex 1 tablet once daily started one week ago.
Ibuprofen 200mg four every 8 hours as needed for pain.
Allergies: No known allergies to food, medications, or environmental allergens.
PMHx: No previous significant illnesses or surgeries were reported.
Immunizations: Up to date childhood immunizations. Has had influenza vaccine within the
current influenza season. The last tetanus vaccine was 01/22/2023.
Soc Hx: J.O. works full-time as a manager in a hospital-based call center. He is single and lives
alone. He smokes one pack of cigarettes weekly and drinks six to twelve beers every two weeks
with friends.
Page 1 of 20
,Fam Hx:
Mother: Hypertension, obesity
Father: Smoker, Hypertension, Obesity, Passed away at 52 due to a Myocardial
Infarction.
Maternal Grandmother: Type 2 Diabetes, Hypertension- Died at 82 due to ischemic
stroke.
Maternal Grandfather: Smoker, Eczema
Paternal Grandmother: Died in a car accident at the age of 52.
Paternal Grandfather: Hypertension, Colon Cancer
ROS:
GENERAL: Patient denies recent weight loss. He has had no recent weakness or fatigue. He
appears uncomfortable while sitting in the exam room answering questions.
HEENT: Patient denies visual changes. He reports having a recent vision exam. He denies
hearing changes or concerns about swallowing.
SKIN: Patient denies rashes, sores, or concerns.
CARDIOVASCULAR: Patient denies chest pain, palpitations, dizziness, or swelling.
RESPIRATORY: No shortness of breath or respiratory concerns were reported.
GASTROINTESTINAL: Denies nausea, vomiting, or diarrhea. The patient reports that GERD
symptoms are controlled with current medications.
GENITOURINARY: No concerns with urinary frequency or hesitancy.
NEUROLOGICAL: Patient denies paralysis, numbness, or tingling in the extremities—no
change in bowel or bladder control.
MUSCULOSKELETAL: Has decreased ROM bending forward and denies a history of arthritis
or previous injuries.
PSYCHIATRIC: Patient admits to feelings of anxiety and depression related to the ongoing pain
he is experiencing.
Page 2 of 20
, O.
Physical exam:
Vital signs:
B/P: 150/98, left arm, sitting, regular cuff Pulse: 90 and regular rate.
Temperature: 98.6 Orally RR: 16; non-labored
Weight: 300 lbs. Height: 5’8” BMI: 45.6
GENERAL: J.O. is a well-nourished Caucasian male who is pleasant, alert, and cooperative. He is
answering questions appropriately. He appears to be having discomfort during the exam.
HEENT: Atraumatic without lesions noted. Glasses in place. PEARL, EOMs intact. Ears
symmetrical, no tenderness or discharge noted.
HEART/PERIPHERAL VASCULAR: Heart rate regular without murmur, rub, or gallop; pulses+2
bilat pedal and +2 radial.
ABD: No scars noted, abdomen soft and non-tender to palpation throughout all quadrants. No
masses noted, bowel sounds present, and no organomegaly noted.
MUSCULOSKELETAL: Patient is fully weight-bearing. He has decreased ROM to bilateral lower
extremities.
Neuro: CN II – XII grossly intact, sensation intact, strength 5/5, and is equal bilaterally. Reflexes are
noted 2+ and equal bilaterally, and no cerebellar dysfunction is noted.
Diagnostic results:
X-ray of spine
MRI
Please see page 3 for the rationales for the tests ordered.
Page 3 of 20
Patient Name: J.O. Age: 42 Sex: Male
Race: Caucasian
S.
CC: “pain in lower back”
HPI: J.O., a 42-year-old Caucasian male, presents to the clinic due to reports of pain in his lower
back that started about one month ago. He describes the pain as sharp and shooting pain that
sometimes radiates to his left leg. He denies associated symptoms and states that it seems to
happen intermittently throughout the day, depending on his activity. He reports that it worsens
after he has been on his feet or walking around for a long time. He states that it improves some
when he lays or sits down to rest. 800mg of ibuprofen every eight hours makes the pain
tolerable, and his pain rating is an 8/10 on the pain scale. He has tried applying ice and heat,
which slightly alleviates the pain. There has been no known recent injury.
Current Medications:
Pantoprazole 40mg once daily for GERD- started one year ago.
Lisinopril 10mg once daily for HTN- started two years ago.
Osteo Bi-Flex 1 tablet once daily started one week ago.
Ibuprofen 200mg four every 8 hours as needed for pain.
Allergies: No known allergies to food, medications, or environmental allergens.
PMHx: No previous significant illnesses or surgeries were reported.
Immunizations: Up to date childhood immunizations. Has had influenza vaccine within the
current influenza season. The last tetanus vaccine was 01/22/2023.
Soc Hx: J.O. works full-time as a manager in a hospital-based call center. He is single and lives
alone. He smokes one pack of cigarettes weekly and drinks six to twelve beers every two weeks
with friends.
Page 1 of 20
,Fam Hx:
Mother: Hypertension, obesity
Father: Smoker, Hypertension, Obesity, Passed away at 52 due to a Myocardial
Infarction.
Maternal Grandmother: Type 2 Diabetes, Hypertension- Died at 82 due to ischemic
stroke.
Maternal Grandfather: Smoker, Eczema
Paternal Grandmother: Died in a car accident at the age of 52.
Paternal Grandfather: Hypertension, Colon Cancer
ROS:
GENERAL: Patient denies recent weight loss. He has had no recent weakness or fatigue. He
appears uncomfortable while sitting in the exam room answering questions.
HEENT: Patient denies visual changes. He reports having a recent vision exam. He denies
hearing changes or concerns about swallowing.
SKIN: Patient denies rashes, sores, or concerns.
CARDIOVASCULAR: Patient denies chest pain, palpitations, dizziness, or swelling.
RESPIRATORY: No shortness of breath or respiratory concerns were reported.
GASTROINTESTINAL: Denies nausea, vomiting, or diarrhea. The patient reports that GERD
symptoms are controlled with current medications.
GENITOURINARY: No concerns with urinary frequency or hesitancy.
NEUROLOGICAL: Patient denies paralysis, numbness, or tingling in the extremities—no
change in bowel or bladder control.
MUSCULOSKELETAL: Has decreased ROM bending forward and denies a history of arthritis
or previous injuries.
PSYCHIATRIC: Patient admits to feelings of anxiety and depression related to the ongoing pain
he is experiencing.
Page 2 of 20
, O.
Physical exam:
Vital signs:
B/P: 150/98, left arm, sitting, regular cuff Pulse: 90 and regular rate.
Temperature: 98.6 Orally RR: 16; non-labored
Weight: 300 lbs. Height: 5’8” BMI: 45.6
GENERAL: J.O. is a well-nourished Caucasian male who is pleasant, alert, and cooperative. He is
answering questions appropriately. He appears to be having discomfort during the exam.
HEENT: Atraumatic without lesions noted. Glasses in place. PEARL, EOMs intact. Ears
symmetrical, no tenderness or discharge noted.
HEART/PERIPHERAL VASCULAR: Heart rate regular without murmur, rub, or gallop; pulses+2
bilat pedal and +2 radial.
ABD: No scars noted, abdomen soft and non-tender to palpation throughout all quadrants. No
masses noted, bowel sounds present, and no organomegaly noted.
MUSCULOSKELETAL: Patient is fully weight-bearing. He has decreased ROM to bilateral lower
extremities.
Neuro: CN II – XII grossly intact, sensation intact, strength 5/5, and is equal bilaterally. Reflexes are
noted 2+ and equal bilaterally, and no cerebellar dysfunction is noted.
Diagnostic results:
X-ray of spine
MRI
Please see page 3 for the rationales for the tests ordered.
Page 3 of 20
