iHuman Case Study: 69-Year-Old Male with Chest Pain (Class 6531) in Outpatient Clinic with X-Ray, ECG, and Laboratory Capabilities | Latest Update | Comprehensive Analysis with All Sections.

iHuman Case Study: 69-Year-Old Male with Chest Pain (Class 6531) in Outpatient Clinic with X-Ray, ECG, and Laboratory Capabilities | Latest Update | Comprehensive Analysis with All Sections.

VERSION B
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
Case: Sam Newton
Date: April 4, 2021
PMHx child/adult
illness/hospitalizations/immunizations
• No serious childhood illnesses except for
common colds, coughs, and stomach
pain
• Benign prostatic hyperplasia, high blood
pressure, hepatitis C.
• No hospitalization
SurgHx type/when/why/complications
• No surgical history
FamHx
Grandparents (if known)/Parents/siblings/children
• No history on grandparents
• Both parents were healthy and died from
old age
• No children
SHx
Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships
• Smoked a pack of cigarette a day for 30 years but quit 5 years ago
• History of intravenous drug use (Heroin); he has been clean for 30 years
• He has down on alcohol consumption; He used to take 4-5 beers a day,
but he has cut down.
• Patient works as a environmental cleaning car driver
Reproductive Hx
Female: Age of menarche/menstruation cycle
duration/gravida para status/Childbirth hx/sexual hx and
concerns/LMP/menopause
Breast/cervical screening (if any)
Male: Sexual hx and concerns/issues with fertility (if
any)/Testicular or prostate screening (if applicable)
Screening for STI’s (if applicable)
• Patient refused to answer question about
STDs
• He reports he is heterosexual
Allergies (Food, Drug, Environmental, etc.)
• NKA
List of Medications/supplements (prescription, OTC, complementary
alternative therapies)
• Tamsulosin (Stopped taking it 5 years ago)
• BP medication (Stopped taking it 5 years ago)
• Tylenol
• Motrin 

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