History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Essential Differential Diagnosis
Relevant Next Steps
Test Result 1
Essential Immediate Steps
Question 1
Question 2
Question 3
About the Case
Dyspnea and Back Pain in a 24-yr-old Man
Past Medical History
Medical history
: None; sees a physician regularly for routine physicals. No history of similar illness or symptoms.
Surgical history
: None
Medications
: None
Allergies
: None
Family history
: Both parents are alive; father has hypertension; mother is well. Maternal grandfather may have died of lung cancer. No known coronary artery disease in family.
Social history
: Lives with his parents and works full-time in a grocery store; does occasional light lifting without difficulty. Smokes 7 to 10 cigarettes/day, which is decreased from 1 pack/day. Drinks alcohol once/wk to once/mo. Used marijuana in his teens.
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