Back Pain Sample Patient Note
Rahul's Noteblog USMLE CS Notes and Mnemonics Back Pain Patient Note
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
Medical Images
Useful Medical Images & Diagrams (link opens in a new window)
Random Pages:
Please Do Not Reproduce This Page
This page is written by Rahul Gladwin. Please do not duplicate the contents of this page in whole or part, in any form, without prior written permission.