SAM NEWTON 62 YEAR OLD MALE CC SEVERE LOWER BACK PAIN
EXPERT FEEDBACK (ANSWERS) 2023UPDATE
CONTENTS : OLD-CARTS for the HPI,(PMH,FH,SH as Needed),PHSICAL EXAM,EXAMS FEEDBACK,CASE
FINDINGS,FEEDBACK,DIFFERENTIAL RANKING ,DIAGNOSIS,CASE PLAN, List the differential diagnoses (Must not
Miss/Leading/Alternate/Concluding)
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