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Old 07-15-2012
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Help please help me check my PN for back pain

Hi all: I posted my complete PN for back pain, please help me check and tell me what you think. many thanks!

HPI: 51 yo m c/o back pain for 1 wk. He has this pain after he lifted heavy boxes. The pain is always the same, 8/10 in severity, located in the middle part of the lower back; moves to the left thigh and foot; lying down makes it better, walking, coughing and sitting makes it worse. Has back pain on and off for past 6 mo; also pain in the legs, better when he stoped walking and sit down. Also has problem in urination; has urinary hesitancy and straining. No nausea, vomiting, fever, chills
ROS: negative except as above
Allergies: Penicillin
PMH/ PSH: none
SH: no smoking, EtOH, drugs, works as a construction worker, sexaully active with wife FH: noncontributory





patient is in no acute distress
VS: WNL
heart: RRR, normal S1/S2, nomurmurs, rubs, gallops
chest: CTA&P/BL
abd: soft, nondistended, +BS, nohepatosplnomegaly
back: lower back paraspinal tenderness, limited range of motion






muscle strain:
pain after he lifted heavy boxes


disc herniation:
walking, coughing and sitting makes it worse
pain after he lifted heavy boxes


BPH:
problem in urination; has urinary hesitancy and straining


rectal exam, genital exam
MRI-spinal cord
XR-abd(PA and lateral)
blood culture
CT- abd, lumbar spine
PSA
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  #2  
Old 07-15-2012
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Thumbs Up Not bad.

Since its back pain you should do NEURO On physical exam. Sensation, DTR's, Pulses, and motor strength in the least.

Quick things to help you go faster and shorten yous Pt Note
Middle part of the lower back = Lumbar region
He has this pain after = Pain began
The pain is always the same = Constant pain
makes it better = Alleviated by / Improved with
makes it worse = Aggravated by

lying down makes it better, walking, coughing and sitting makes it worse - Alleviated when lying and aggravated by walking, sitting and coughing.


Under your differentials you can add the paraspinalis tenderness and decrease in Range of motion to the PE Findings to support your diagnosis.

Also what happens when he takes penicillin? Rash or SOB (not necessary if you forget but nice if you have it.)


Hope these tips help you. For the most part pretty nicely done!
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The above post was thanked by:
chienpolska (07-15-2012)



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