A diagnosis on a patient is important and crucial in getting to the bottom of the underlying issue in a patient. It is important to review and work with ihuman case studies as they help evaluate through interview questions, the patient's problem.
Below is a sample ihuman case study of Carlotta. A. Russe
Problem Statement
Ms. Russe is 65 year old female who presents with the acute onset of LBP (scale 7/10) 2 days ago following the moving of heavy tables at work. The pain starts in her back and radiates down her right leg impairing both gait and sleep. Physical examination demonstrates positive straight leg raise on both R with positive finding with contralateral leg raise, RLE sensory, motor and reflex deficits. She denies fevers/chills/night sweats, bladder/bowel dysfunction and denies unintentional weight loss. Significant PMH is her osteoporosis, 40 pack year smoking history and history of steroid use.
General Assessment
Vitals: Temperature, Pulse, Respiration, BP, Mental Status Breast: Breast Exam
Heart: Auscultate heart
Chest wall & Lungs: Auscultate lungs Abdomen: Palpate Abdomen
Musculoskeletal: Inspect/palpate back and spine, test range of motion, test strength
Neurological: Assess gait & stance, Reflexes: Deep tendon and Plantar/Babinski (L5/S1), Sensory tests
Key Findings
Acute onset LBP radiating down right leg following lifting tables: MSAP RLE
Sensory deficit: RELATED
RLE motor deficit: RELATED
Hyporeflexia: right patellar tendon: RELATED
Positive right straight leg raising (SLR) test; positive contralateral SLR: RELATED Asthma: UNRELATED
Hypertension: UNRELATED Osteoporosis: UNKNOWN
Postmenopausal status: total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH BSO): UNKNOWN
40 pack year history of smoking: UNKNOWN History of systemic steroid use: UNKNOWN
Systems Affected
Respiratory, Neurological, and Musculoskeletal
Diagnosis
Carlotta diagnosis is Disk herniation. Differential diagnosis is : Spinal neoplasm and Compression fracture.
Plan
Prescribe Analgesics: NSAIDS or acetaminophen, or narcotics if pain is refractory and only for short term use.
Refer to physical therapy
Consider epidural steroids injections
Monitor longitudinally for surgical indications
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