Case Study on 48 year old male

The 48 year old male explains they have a six month history of intermittent back pain. The pain has been mainly around his lower back area, at times radiates to shoulders. He describes the pain as a dull throb which at times gives him a sense of dread. The pain may last for a few hours or ease on rest. He also describes an increase of epigastric pain over the past few months, which he believes to be heartburn and takes over the counter antacids when required. He presented to the ED as the pain was more severe and prolonged, was radiating down his back and associated with nausea. He has noted trouble passing urine at times.
Personal history: The patient is a 48 year old married administration officer. He exercises occasionally; he has gained weight in the last six months. He has 2 dependent children and his wife works as child care assistance. He tells you that he has an alcohol intake of 1-2 standards drinks per day and occasionally binge drinks on the weekend.
Family history: The patients’ father suffers from peripheral neuropathy and is medicated for hypertension. His mother had a cholecystectomy due to gall stones, a hysterectomy for cervical cancer and is taking medication for high cholesterol.
Past medical/ surgical history: The patient had a R knee arthroscopy in 2011. Current medication Glucosamine 1500 mg.
• Respiratory rate 24 breaths per minute
• Sp02 94% on room air
• Heart rate is 110 beats per minute
• Blood pressure is 150/ 90 mm Hg
• Temperature is 36.3°C

Table of Contents

Systems review

NEUROLOGICAL: GCS is 15/15 with pupils equal and reactive to light (PEARL).
RESPIRATORY Inspection: The patient displays comfortable breathing, nil cough. There are no abnormal thoracic landmarks or scars.
Palpation: Chest expansion is symmetrical. There is slight tenderness on lower midline area.
Percussion: Lung fields clear, resonant sounds.
Auscultation: There is air entry into all lung fields. Fine crackles can be auscultated on inspiration.
CARDIOVASCULAR Inspection: The patient is centrally pink; however lower limb peripheral blanching is present.
Palpation: Peripheral pulses are palpable at +1. Calves are soft and non-tender. Jugular venous pressure (JVP) is less than 4cm. Palpable abdominal pulse present.
Auscultation: Heart sounds of S1 & S2 are heard. There is no murmur.
An ECG confirmed sinus tachycardia and a portable chest radiograph showed shading in lower Left lung fields and midline area.
An arterial blood gas shows a pH 7.30, Pa02 78 mm Hg, PCO2 58 mm Hg, HCO3 27 mEq/L, and Lactate 2.1 mm Hg. Spirometry results include FEV1/FVC of 75%.

ABDOMINAL Inspection: The patient is sitting up, signs of distress with pained facial expression. Skin is pink and warm, patient is sweating. Abdomen not distended visible pulsations midline. No bruising, striae, surgical scares or lesions. The abdominal wall is moving symmetrically with respirations. The flanks are clear of bulges. No evidence of Cullen’s sign and Grey Turner’s sign.
Auscultation: Bowel sounds are minimally present and bruits heard midline.
Palpation: The patient has moderate midline and back pain, increases when lying flat. No crepitus, rigidity, rebound tenderness, referred tenderness, or masses palpated. During deep palpation tenderness over the midline region is noted.
Percussion: Abdomen is resonant to percuss.

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