WEEK #9: I-HUMAN CASE – 54 YEAR-OLD WITH BACK PAIN,90+ SCORE GURANTEED ABOVE 6512,6531,6541,6550,6560.

WEEK #9: I-HUMAN CASE – 54 YEAR-OLD WITH
BACK PAIN,90+ SCORE GURANTEED ABOVE
6512,6531,6541,6550,6560.




PATIENT DETAILS
 Age: 54 years
 Gender: Male
 Height: 5’10’’ (178 cm)
 Weight: 155 lbs (70.5 kg)
 Location: Outpatient clinic with X-ray, ECG, and laboratory capabilities
 Reason for Encounter: Back pain

, CHIEF COMPLAINT
"I’ve been having back pain."




HISTORY OF PRESENT ILLNESS (HPI)
The patient is a 54-year-old male presenting with back pain. The pain is localized to the lower
back and is consistent with mechanical back pain. He denies any recent trauma. He reports no
radiation of pain, no numbness or tingling, and no weakness. There is no bowel or bladder
incontinence. Symptoms prompted evaluation in an outpatient clinic with imaging and laboratory
capabilities.




REVIEW OF SYSTEMS (ROS)
 General: Denies fever, chills, night sweats, or unexplained weight loss
 HEENT: Denies headache, vision changes
 Cardiovascular: Denies chest pain, palpitations
 Respiratory: Denies shortness of breath
 Gastrointestinal: Denies abdominal pain, nausea, vomiting
 Genitourinary: Denies urinary retention, urinary or fecal incontinence
 Musculoskeletal: Positive for back pain
 Neurological: Denies weakness, numbness, tingling, or saddle anesthesia
 Psychiatric: Denies anxiety or depression




PAST MEDICAL HISTORY
 Not specified / no known chronic medical conditions reported




SURGICAL HISTORY
 Denies prior surgeries