Case Scenario, Essay Example

Case Scenario: Mr. Smith is a 48-year old man who presents to your office complaining of back pain radiating to his right hip.

Vital signs: BP 138/75 mmHg; HR 80 bpm, regular; RR 16 rpm; Temp 98.2°F

Differential Diagnoses:  List at least 4 differential diagnoses that should be included for the above chief complaint.

History: Use the space below to list the questions you would ask to obtain a full history of present illness (HPI).

Physical Exam: Use the space below to document your physical findings.  Use creativity to describe findings that you would expect with one of the diagnoses you listed above.  Indicate the diagnosis you chose at the end of your physical exam.  Include all appropriate exams you have learned to date. (i.e. you would likely examine the cardiac and pulmonary systems in a patient with a complaint of chest pain)

Management: List below the lab tests and one imaging study you would order for this patient.  Give a brief indication/justification for each test. (i.e. Chest x-ray – to determine if the patient has an infiltrate.  Avoid use of “rule out” – aka “to rule out pneumonia”).