Week 7 - History of present illness- A 35-year-old male

MSWK7

Chief complaint - “My back hurts so bad I can barely walk”

History of present illness- A 35-year-old male painter presents to your clinic with the complaint of low back pain. He recalls lifting a 5-gallon paint can and felt an immediate pull in the lower right side of his back. This happened 2 days ago and he had the weekend to rest, but after taking Motrin and using heat, he has not seen any improvement. His pain is sharp, stabbing, and he scored it as a 9 on a scale of 0 to 10.

Drug HX- Motrin for pain.

Family HX- Father hypertension, Mother DM

Subjective- He is having some right leg pain but no bowel or bladder changes. No numbness or tingling

Vital signs- temperature: 98.2°F, respiratory rate 16, heart rate 90, blood pressure 120/60 O2 saturation 98%

General- well-developed healthy 35-year-old male; no gross deformities

HEENT- Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries.

Lungs- CTA AP&L

Cardiac- S1S2 without rub or gallop

Breast-  INSPECTION: no dimpling or abnormalities noted upon inspection, PALPATION: Left breast - no abnormalities noted. Right breast - denies tenderness, pain, no abnormalities noted.

Lymph- no bruising, fever, or swelling noted, no acute bleeding or trauma to skin.

Abdominal- benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin

GU-Bladder is non distended

Integument- intact without lesions masses or rashes.

MS- No obvious deformities, masses, or discoloration. Palpable pain noted at the right lower lumbar region. No palpable spasms. ROM limited to forward bending 10 inches from floor; able to bend side to side but had difficulty twisting and going into extension. 

Neuro- DTRs 2+ lower sensory neurology intact to light touch and patient able to toe and heel walk. Gait was stable and no limping noted.

1. What other subjective data would you obtain?

2. What other objective findings would you look for?

3. What diagnostic exams do you want to order?

4. Name 3 differential diagnoses based on this patient presenting symptoms?

5. Give rationales for your each differential diagnosis.

6. What teachings will you provide?