Back Pain Sample Patient Note

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HPI

75 YO F C/O CONTINUOUS BACK PAIN (LOWER MIDDLE BACK, 7/10, STABBING, RADIATING TO THE LEFT LEG); MOVEMENT MAKES IT WORSE AND SITTING MAKES IT GO AWAY. NO PREVIOUS EPISODES; PAIN BEGAN SUDDENLY AFTER PT TRIPPED ON SIDE WALK; GETTING WORSE. PATIENT DENIES SWELLING, REDNESS, LOCKING SENSATION, POPPING NOISE, DISTURBANCE FROM SLEEP, INCONTINENCE, AND TRAUMA. PATIENT ALSO DENIES BURNING, NUMBNESS, WEAKNESS, AND PARALYSIS.

ROS- NO CHILLS, HEADACHE, FEVER, JOINT PAIN, RASH, INFECTION, SWELLING OF FEET, CHEST PAIN.

PMH/PSH- BREAST CANCER

NKDA

MEDICATIONS/HOSPITALIZATIONS- NONE

SH- SMOKING-, RETIRED TEACHER, DRUGS-. ALCOHOL-, WIDOW, 2 CHILDREN; LIVES ALONE; GOOD SOCIAL SUPPORT.

FH- NOT CONTRIBUTORY

OB- MENOPAUSE AT AGE 50; NO HOT FLASHES; NO VAGINAL BLEEDING; NO VAGINAL DRYNESS.

PHYSICAL EXAM

GA- PATIENT IN MILD DISTRESS

HEENT- NC/NT, PINK CONJUNCTIVA, PINK PHARYNX

NECK- NO LUMPS, NO THYROMEGALY

BACK- NO SWELLING, DEFORMITIES, RASH.

MUSCLE STRENGTH- 5/5 UE AND LE B/L.

REFLEXES- 2+ UE AND LE B/L.

SENSATION- SOFT AND SHARP TOUCH INTACT UE AND LE B/L.

PULSES- 2+ SYMMETRIC UE AND LE B/L.

GAIT- WNL, ROMBERG-, STRAIGHT LEG RAISING TEST-.

DIFFERENTIAL DX

METASTATIC BREAST CANCER

HISTORY PHYSICAL EXAM
CONTINUOUS BACK PAIN
7/10 STABBING
RADIATING TO THE LEFT LEG
MOVEMENT MAKES IT WORSE
RESTING MAKES IT BETTER
NO SWELLING
NO REDNESS
NO LOCKING SENSATION
NO POPPING NOISE
NO DISTURBANCE FROM SLEEP
NO INCONTINENCE

LUMBAR MUSCLE SPRAIN

HISTORY PHYSICAL EXAM
PAIN BEGAN AFTER TRIPPING ON SIDE WALK
CONTINUOUS BACK PAIN
7/10 STABBING
RADIATING TO THE LEFT LEG
MOVEMENT MAKES IT WORSE
RESTING MAKES IT BETTER
NO SWELLING
NO REDNESS
NO LOCKING SENSATION
NO POPPING NOISE
NO DISTURBANCE FROM SLEEP
NO INCONTINENCE

TESTS

CBC

ELECTROLYTES

LUMBAR XRAY AND U/S

DEXA SCAN

Additional Readings:

USMLE CS Sample Patient Notes

1. Testicular Pain
2. Mid-Epigastric Pain
3. Back Pain

USMLE Step 2 CS Videos

1. Video of Cardiology Examination in a Clinical Setting
2. Video of Neurology Examination in a Clinical Setting
3. Video of Pulmonology Examination in a Clinical Setting
4. Video of Musculoskeletal Examination in a Clinical Setting
5. Video of Abdominal Examination in a Clinical Setting
6. Video of HEENT Examination in a Clinical Setting
7. Video and Description of Rinne Hearing Test
8. Video and Description of Weber Hearing Test

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