H&P #3

Identifying Data

Full Name: B. W.

Sex: Male

DOB: xx/xx/1960

Date & Time: October 25, 2023

Location: Metropolitan Hospital

Source of Information: Self

Reliability: Reliable

Source of referral: Self

Mode of transportation: Taxi

 

Chief Complaint: “back pain” x 2 weeks

 

History of Present Illness:

63 y/o M with PMHx HTN presents to the ED c/o right sided back pain x 10 days. As per patient, pain began about 203 days after being handcuffed and placed in the back of a small police car where he states they “hit every bump” causing the right side of his back to repeatedly hit the seat. Describes pain as 8/10 stabbing sensation that worsens with movement. Pt reports pain has been intensifying over the past 3 days. Pain occasionally shoots down the arm to the wrist and is associated with a tingling sensation. Pt took 1 dose of ibuprofen 600 mg yesterday, no relief. Denies trauma, previous back injuries, numbness, urinary/bowel incontinence, saddle anesthesia, fever, chills, SOB, chest pain.

 

Differential diagnosis:

  1. MSK pain
  2. Degenerative disc disease
  3. Herniated disc
  4. Spinal stenosis

 

Past Medical History

Medical History:

  • HTN, controlled with lifestyle modifications
  • No past hospitalizations or history of blood transfusions.

Medications:

  • No prescription medication use.
  • Denies herbal supplement use.

Surgical History:

  • No past surgical history.

Allergies:

  • No known drug/food/environmental allergies

Family History:

  • Mother: Age 90s, alive and well. PMHx HTN, DM2
  • Father: Unknown
  • No known family hx MI or cancer.

Social History:

  • Smoking: Never
  • Alcohol: Socially, 1-2 beers every few weeks
  • Denies past or current illicit drug use
  • Marital History: Married
  • Language: English
  • Occupational History: Retired veteran
  • Travel: No recent travel
  • Home situation: Lives in Queens apt with wife
  • Sleep: Endorses adequate sleep
  • Exercise: Reports daily exercise
  • Diet: Reports balanced diet
  • Caffeine: Denies caffeine use.

 

ROS:

  • General: Denies fever, fatigue, chills, night sweats, weight loss/gain, changes in appetite.
  • Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
  • HEENT: Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, discharge, congestion, sore throat, bleeding gums.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Pulmonary: Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
  • Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, constipation.
  • Genitourinary: Denies urinary urgency, urinary frequency, dysuria, hesitancy, dribbling.
  • Musculoskeletal: Admits to back pain and arm tingling. Denies muscle pain, joint pain, arthritis, or swelling.
  • Nervous system: Denies headache, loss of strength, change in cognition/mental status/memory.
  • Peripheral vascular: Denies intermittent claudication, coldness of extremities, peripheral edema.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
  • Endocrine: Denies polydipsia, heat or cold intolerance, excessive sweating.
  • Psychiatric: Denies depression or anxiety.

 

Physical Exam:

Vitals:

  • Weight: 250 lb Height: 78 inches       BMI: 28.9 kg/m2
  • BP: 114/75, left arm sitting
  • RR: 16, unlabored
  • HR: 78, regular
  • Temp: 98.6 F oral
  • SpO2: 99% room air

General: 63-year-old male who appears stated age. A/O x 3 and sitting comfortably in chair.

HEENT: Normocephalic & atraumatic; PERRL; EOM intact.

Neck: Trachea midline. Neck supple and non-tender.

Heart: Regular rate and rhythm. S1 & S2 distinct with no murmurs or gallops.

Lungs: Clear to auscultation B/L. No adventitious sounds noted.

Abdominal: Abdomen symmetric and non-distended, with no scars. Normoactive bowel sounds in all 4 quadrants. No tenderness, no guarding or rebound.

Musculoskeletal: Full passive and active ROM of all extremities and back. Skin warm and intact, pulses intact. + Right sided para-spinal muscle tenderness. Arm strength and grip strength 5/5. Negative straight leg test B/L.

 

Assessment/Plan:

63 y/po M with PMHx HTN c/o right sided back pain and right arm tingling x 10 days after being handcuffed 2 weeks ago. Currently hemodynamically stable and in no acute distress. PE reveals FROM and right sided para-spinal muscle tenderness.

 

#Back pain

  • Lidocaine patch
  • Motrin 600 mg
  • Robaxin 1000mg
  • Reassess

 

Dispo: Discharge home

  • Patient reported improvement of symptoms after receiving Motrin and lidocaine patch
  • ER precautions given: SOB, chest pain, fever, urinary/bowel incontinence
  • Follow up with PCP
  • Patient feels well and wishes to go home. Verbally acknowledges and agrees with plan, discharge instructions and follow up give. All questions answers and concerns addressed.