I-HUMAN CASE STUDY WEEK #9 54 YEAR OLD MALE
HEIGHT: 5”10”(178cm) WEIGHT:
155.0lb(70.5kg)REASON FOR ENCOUNTER:BACK
PAIN LOCATION OUTPATIENT CLINIC WITH X-RAY
WITH LABORATORY CAPABILITIES LATEST
2025!!!(Class 6550)
,Patient Introduction:
This is a 54-year-old male who presented with complaints of back pain. The pain has been
ongoing for [insert duration, e.g., "several weeks"] and is described as [insert pain
characteristics, e.g., "dull," "sharp," "radiating to the legs," etc.]. There is no significant history
of trauma, and no prior similar episodes have been reported. Relevant medical, surgical, and
family history will be explored further to determine contributing factors.
Certainly! Here is a sample History of Present Illness (HPI) for a 54-year-old patient with back
pain:
HPI:
The patient is a 54-year-old male who presents with a complaint of lower back pain that began
approximately [insert duration, e.g., "three weeks ago"]. He describes the pain as [e.g., "dull and
aching"] and localized to the lower lumbar region. The pain is [e.g., "constant but worsens with
prolonged standing or physical activity"]. He denies any recent trauma, heavy lifting, or
strenuous activity prior to the onset of symptoms.
He rates the pain as [insert pain score, e.g., "6/10"] at its worst. The pain does not radiate to the
legs, and he denies any numbness, tingling, or weakness in the lower extremities. He also denies
bowel or bladder incontinence, fever, chills, or unexplained weight loss.
The patient reports some relief with over-the-counter analgesics and rest, but the pain persists
and interferes with his daily activities and sleep. There is no known history of similar back issues
in the past.
"Past Medical History" (PMH) refers to a patient's previous health conditions, illnesses,
surgeries, hospitalizations, and any ongoing medical issues. It's a key component of a medical
history used by healthcare providers to understand a patient's overall health status.
A typical PMH includes:
1. Chronic conditions
o e.g., Diabetes, Hypertension, Asthma, COPD, Heart disease
2. Past illnesses or infections
o e.g., Tuberculosis, Hepatitis, HIV, Pneumonia
, 3. Surgeries and procedures
o e.g., Appendectomy, Cesarean section, Coronary artery bypass grafting (CABG)
4. Hospitalizations
o When and why the patient was hospitalized
5. Allergies
o To medications, food, or environmental factors
6. Medications
o Current or long-term medications taken in the past
7. Gynecologic/obstetric history (if applicable)
o e.g., Pregnancies, miscarriages, deliveries
8. Psychiatric history
o e.g., Depression, Anxiety, Schizophrenia
9. Family history (brief mention if relevant)
o May be included separately or referenced if related to the patient's conditions
Example PMH Entry:
Past Medical History:
Type 2 Diabetes Mellitus (diagnosed 2015)
Hypertension (since 2010)
Myocardial Infarction (2018)
Appendectomy (childhood)
Allergic to penicillin
No history of psychiatric illness
"Family and social history" typically refers to sections in a medical, psychological, or social
assessment that provide background on a person's familial and social context. Here’s a
breakdown of what’s usually included in each:
Family History
This section covers information about a person's biological relatives and their health conditions.
It helps assess genetic or hereditary risks.
Common elements include:
Medical conditions in parents, siblings, grandparents (e.g., diabetes, hypertension,
cancer, mental illness).
Cause and age of death of any deceased family members.
Genetic disorders or congenital conditions.
Substance use history in the family.
Mental health history, including depression, anxiety, or psychiatric disorders.
HEIGHT: 5”10”(178cm) WEIGHT:
155.0lb(70.5kg)REASON FOR ENCOUNTER:BACK
PAIN LOCATION OUTPATIENT CLINIC WITH X-RAY
WITH LABORATORY CAPABILITIES LATEST
2025!!!(Class 6550)
,Patient Introduction:
This is a 54-year-old male who presented with complaints of back pain. The pain has been
ongoing for [insert duration, e.g., "several weeks"] and is described as [insert pain
characteristics, e.g., "dull," "sharp," "radiating to the legs," etc.]. There is no significant history
of trauma, and no prior similar episodes have been reported. Relevant medical, surgical, and
family history will be explored further to determine contributing factors.
Certainly! Here is a sample History of Present Illness (HPI) for a 54-year-old patient with back
pain:
HPI:
The patient is a 54-year-old male who presents with a complaint of lower back pain that began
approximately [insert duration, e.g., "three weeks ago"]. He describes the pain as [e.g., "dull and
aching"] and localized to the lower lumbar region. The pain is [e.g., "constant but worsens with
prolonged standing or physical activity"]. He denies any recent trauma, heavy lifting, or
strenuous activity prior to the onset of symptoms.
He rates the pain as [insert pain score, e.g., "6/10"] at its worst. The pain does not radiate to the
legs, and he denies any numbness, tingling, or weakness in the lower extremities. He also denies
bowel or bladder incontinence, fever, chills, or unexplained weight loss.
The patient reports some relief with over-the-counter analgesics and rest, but the pain persists
and interferes with his daily activities and sleep. There is no known history of similar back issues
in the past.
"Past Medical History" (PMH) refers to a patient's previous health conditions, illnesses,
surgeries, hospitalizations, and any ongoing medical issues. It's a key component of a medical
history used by healthcare providers to understand a patient's overall health status.
A typical PMH includes:
1. Chronic conditions
o e.g., Diabetes, Hypertension, Asthma, COPD, Heart disease
2. Past illnesses or infections
o e.g., Tuberculosis, Hepatitis, HIV, Pneumonia
, 3. Surgeries and procedures
o e.g., Appendectomy, Cesarean section, Coronary artery bypass grafting (CABG)
4. Hospitalizations
o When and why the patient was hospitalized
5. Allergies
o To medications, food, or environmental factors
6. Medications
o Current or long-term medications taken in the past
7. Gynecologic/obstetric history (if applicable)
o e.g., Pregnancies, miscarriages, deliveries
8. Psychiatric history
o e.g., Depression, Anxiety, Schizophrenia
9. Family history (brief mention if relevant)
o May be included separately or referenced if related to the patient's conditions
Example PMH Entry:
Past Medical History:
Type 2 Diabetes Mellitus (diagnosed 2015)
Hypertension (since 2010)
Myocardial Infarction (2018)
Appendectomy (childhood)
Allergic to penicillin
No history of psychiatric illness
"Family and social history" typically refers to sections in a medical, psychological, or social
assessment that provide background on a person's familial and social context. Here’s a
breakdown of what’s usually included in each:
Family History
This section covers information about a person's biological relatives and their health conditions.
It helps assess genetic or hereditary risks.
Common elements include:
Medical conditions in parents, siblings, grandparents (e.g., diabetes, hypertension,
cancer, mental illness).
Cause and age of death of any deceased family members.
Genetic disorders or congenital conditions.
Substance use history in the family.
Mental health history, including depression, anxiety, or psychiatric disorders.
