Case Scenario:
DIAGNOSIS: LUMBAR STRAIN OR SPRAIN
History of Present Illness:
Reason for Encounter:
Back Pain
History For Present Illness:
The patient is a 54-year-old male computer programmer with a PMH of HTN, who reports one week of left lower 6 out of 10 back pain described as achy and constant that radiates to the buttocks and is worsened by movement. There is intermittent tingling in the left buttock but no numbness or decreased sensation. He regularly exercises and reports moving to a new house last week, which has necessitated lifting heavy boxes and furniture. He has tried taking acetaminophen without relief and has continued to weightlift and run long distances since symptoms began. Denies recent fall, MVA, or trauma as well as history of cancer, fever, weight loss, bowel/bladder incontinence, difficulty walking, or lightheadedness.
General: As per HPI, denies fever, chill, weight loss or night sweats.
HEENT/NECK: No blurry vision, hearing loss, sore throat, or swollen lymph nodes
Cardio & respiratory: No CP, leg swelling, or palpitations, no cough, SOB or wheezing
Genitourinary: (-) dysuria, nocturia, hematuria, or urinary frequency
Gastrointestinal: (-) nausea, vomiting, or diarrhea
Musculoskeletal/ Osteopathic Structural Examination:
As er HPI
Neurologic: As per HPI
Integumentary/ Breast: No rashes, ecchymoses, or lesions
Psychiatric: denies depressed mood or feeling anxious
Endocrine: denies polyuria, polydipsia, polyphagia, or heat or cold intolerance
Heamatologic/ Lymphatic: Denies easy bruising or bleeding
Allergic/ Immunologic: Denies recent itching or hives
Past Medical History: HTN 1 year ago, controlled by diet and exercise
Hospitalization/ Surgeries: Right rotator cuff repair, 8 months ago, no complications, tolerated anesthesia well
Allergens: penicillin, doxycycline both cause hives
Preventive Health: Annual well checks, last visit 1 month ago
Bianual routine dental visits
Sees an ophthalmologist annually, wears glasses
Immunizations: Up to date, including COVID and Flu
Family history:
Mother: 76 yo, osteoporosis, overweight
Father: 80 yo, HTN, HLD
Sibling: 52 yo brother, HTN
Children: son age 24, no health problems, daughter age 32, no health problems
Social History:
Tobacco: Occasional tobacco smoker x 5-6 years, once per month x 1 cigar
Alcohol: Drinks socially, 1-2 times per month, consumes 1-2 whiskey drinks
Drugs: Denies
Diet: incorporate many vegetables and protein
Activity: avid weightlifter and runs 3-4 miles 3 times a week
Travel: none
Sleep: No problems failing or staying asleep
Stressors: None
Living Situation: Lives with spouse
Support System: Spouse and brother
Occupation: Computer programmer
Finances: Denies Problem
Instruction:
To prepare:
- Review this week’s Learning Resources. Consider how to assess, diagnose, and treat patients with musculoskeletal conditions.
- Access i-Human from this week’s Learning Resources and review the assigned case study.
- Analyze the provided patient history, physical exam findings, and diagnostic test results to support clinical decision-making.
- As you interact with this week’s i-Human patient, complete the assigned case study. For guidance on using i-Human, refer to the i-Human Graduate Programs Help link within the i-Human platform.
Assignment Requirements:
Using the Management Plan Template provided in the learning resources, complete the following components:
1. Problem Statement
- Write a complete problem statement. Present the patient as you would to your preceptor, including subjective and objective findings.
2. Primary Diagnosis with Coding
- Identify the primary diagnosis with the corresponding ICD-10 code.
- Provide a rationale for the primary diagnosis.
- Include CPT codes for the office visit, preventive exam, and any procedures (e.g., vaccine, lab draw, ear lavage) performed during the visit.
3. Evidence-Based Guidelines
- Identify the clinical practice guidelines used to develop the primary diagnosis.
4. Differential Diagnoses
- List 3–5 differential diagnoses (distinct from the primary diagnosis).
- Provide a rationale for each diagnosis.
5. Management Plan
- Include prescribed and over-the-counter medications with drug name, dosage, route, and patient education.
- Detail nonpharmacological treatments and supportive care.
- Specify any required ancillary tests (e.g., ECG, spirometry, X-ray).
- List any necessary referrals (e.g., physical therapy, cardiology, hematology).
6. SDOH, Health Promotion, and Risk Factors
- Address social determinants of health (SDOH), including economic stability, education, healthcare access, neighborhood and environment, and social/community context.
- Outline health promotion strategies, including age-appropriate preventive screenings and immunizations.
- Discuss risk factors related to the primary diagnosis.
7. Patient Education
- Provide comprehensive patient education relevant to the current health visit.
8. Follow-Up
- Include the timeframe for the next visit and specific symptoms that would prompt an earlier return.
9. References
- Use a minimum of three scholarly references from the past five years.
Ensure that all responses are clear, evidence-based, and align with the rubric expectations. Submit the completed assignment in the required format and refer to the Management Plan Template for structure and guidance.