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PATIENT PRESENTATION

Chief Complaint

Back pain

History of Present Illness

CJ is a 62-year-old male who was referred to the hospital by his primary care physician for further workup for back pain. His back pain started six weeks ago and has gotten progressively worse over that time. Stretching and exercise have not helped with the pain. Lying flat in bed provides some relief. The pain is localized to his lower back and gets worse throughout the day. The pain was severe during his physical exam this morning, which is why he was referred to the hospital for further workup. He denies nausea, vomiting, fevers, chills, chest pain, shortness of breath, and bowel or bladder incontinence.

Past Medical History

Hyperlipidemia, hypertension

Family History

Noncontributory

Social History

Denies illicit substances; consumes EtOH socially—approximately three 12 oz beers weekly; lives with his wife of 35 years; employed as an electrician

Allergies

NKDA

Home Medications

Atorvastatin 40 mg PO daily

Lisinopril 40 mg PO daily

Acetaminophen 500 mg PO PRN for back pain

Ibuprofen 400 mg PO PRN for back pain; he has increased use of APAP and ibuprofen over the past 6 weeks

Physical Examination

Vital Signs

Temp 98.4°F, BP 151/98 mm Hg, P 83 bpm, RR 14 breaths per minute, 96% O2 situation on room air, Ht 5′9″, Wt 90 kg

General

He does not appear to be in any acute distress

HEENT

Pupils equal/round, reactive to light, conjunctiva clear; poor dentition noted

Pulmonary

Clear to auscultation bilaterally, no wheezing, rhonchi, or rales

Cardiovascular

Regular rate and rhythm; no appreciable murmurs, gallops, or rubs

Abdominal

Soft, non-tender, non-distended; bowel sounds present

Genital/Rectal

Exam deferred

Extremities

No edema; peripheral pulses intact; normal range of motion; no evidence of injection sites or skin infection

Back

He has reproducible pain in the lumbar spine.

Neurologic

Cranial nerves II–XII are intact. Alert and oriented × 3; mood, affect appropriate

Laboratory Findings

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Na 131 mEq/L

Hgb 14.1 g/dL

AST 35 IU/L

K 4.2 mEq/L

Hct 42%

ALT 40 IU/L

Cl 97 mEq/L

Plt 498 × 103/mm3

Alk Phos 80 ...

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