Discuss the Mr. Payne’s history that would be pertinent to his genitourinary problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
Mr. Payne is a 45-year-old male truck driver that presents with a two-week history of low back pain that radiates down his left leg to his ankle that started after lifting a box while at work. He does have a history of back pain that he states usually goes away within 2-3 days of onset. He states “this is the worst pain I have ever had. He describes the pain as sharp, stabbing and rates it a 7 out of 10 on the pain scale when at its worst. Initially he used ice and took Ibuprofen 400 mg every 6 hours for three days and then tried Naproxen 250 mg once daily for five days. He states that this initial treatment worked, but then he played softball with his daughter and pain returned and has become more constant and not relieved by medication. Pain is aggravated by any movement and sitting for long periods of time. He states that lying down relieves his pain. His job requires him to sit for long periods of time and requires lifting 20-35 pounds 4 hours a day. He has a 20-pack year smoking history but quit 2 years ago. He reports no IV or recreational drug use but does drink a “couple of beers” every now and then on the weekend. He has a history of diabetes, HTN and hyperlipidemia. Current medications include Metformin 1000mg PO twice daily and Glyburide 10mg PO twice daily for diabetes, Amlodipine 2.5 mg PO daily and Lisinopril 40 mg PO daily for HTN, and Simvastatin 40 mg PO daily for hyperlipidemia. He reports no drug allergies. He denies any numbness or weakness in legs, urinary frequency, dysuria, problems with bowel or bladder control, fever or chills, nausea or vomiting, night pain, recent trauma, or weight loss.
Describe the physical exam and diagnostic tools to be used for Mr. Payne. Are there any additional you would have liked to be included that were not?
The physical exam of Mr. Payne included a detailed history of his pain, vital signs, auscultation of the abdomen to assess for bruit (which could indicate an abdominal aortic aneurysm), palpation of the abdomen to check for any masses or tenderness. A standing sitting and supine back exams were also performed. During the standing exam, the patient was observed for any abnormalities in gait, posture, contour, and symmetry of the back. Range of motion and palpation for tenderness were performed. The V. scoop test was also performed. This is where the patient squats from the standing position (this will relieve pain with spinal stenosis). The sitting exam assessed deep tendon reflexes, muscle strength, and sensation of lower extremities. The Supine back exam included abdomen exam, straight leg test, and FABER test to which only the straight leg raise elicited a positive response. At this time, it has only been 2 weeks since the pain has started and there are no red flags that would indicate any further testing such as fever, loss of bladder control, pain that wakes him up at night, or weight loss.