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.
Denies illicit substances; consumes EtOH socially—approximately three 12 oz beers weekly; lives with his wife of 35 years; employed as an electrician
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
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
He does not appear to be in any acute distress
Pupils equal/round, reactive to light, conjunctiva clear; poor dentition noted
Clear to auscultation bilaterally, no wheezing, rhonchi, or rales
Regular rate and rhythm; no appreciable murmurs, gallops, or rubs
Soft, non-tender, non-distended; bowel sounds present
No edema; peripheral pulses intact; normal range of motion; no evidence of injection sites or skin infection
He has reproducible pain in the lumbar spine.
Cranial nerves II–XII are intact. Alert and oriented × 3; mood, affect appropriate