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Sample patient case

Worsening low back pain J Fam Pract. July 2009 (Vol. 58, No. 7).

Sample form

  Chief Complaint: 5/10 dull lower back pain
  Age: 44-year-old 
  Gender: man
  Note: He went to the emergency department (ED), where he reported worsening pain.  
  Blood tests revealed a hemoglobin level of 9.8 g/dL with a hematocrit of 27.9%, 
  serum blood urea nitrogen/creatinine ratio of 143/11.0 mg/dL, potassium of 6.5 mmol/L, 
  calcium of 11.8 mg/dL, and phosphorus of 8.5 mg/dL. Urine protein was elevated at 88 mg/dL. 
  A CT revealed no signs of obstructive uropathy to explain the patient's acute renal failure.
  Medications: nonsteroidal anti-inflammatory agents and an opiate

Patient case description

Chief Complaint