Attending Version: Back Pain Emergencies Module; created by Dr. Wendy Gerstein



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Past medical history: PTSD, BPH

Medications: flexeril, ibuprofen, oxycodone

Social history: lives alone, Vietnam vet, Agent Orange exposure, smokes 1-2 ppd for many years, 2 martinis a day for many years, drug use in past but none in years. Lives in very rural environment, cuts own wood for heating, no running water, very active.

Family history: pancreatic cancer in father

PE: T = 97.2, p= 63, rr =12, bp =110/70

Gen: patient curled in fetal position, uncomfortable-looking, thin, well-groomed

Skin: no rashes/lesions

Heent: completely normal except poor dentition

Lungs: CTAB

CV: reg, s1s2, no mrg heard, apex non-displaced, strong and symmetric pulses, no bruits.

Abd: flat, normal bs, soft, nt/nd, no hsm, no pulsatile masses/bruits

Back: no deformity/redness/swelling; tender to palpation 3 cm lateral to spine at levels t6-t8, surrounding muscles tight and in spasm.

Ext: normal strength, sensation, reflexes.

Neurologic: normal

Labs: cbc and complete metabolic profile is normal (including alk phos, protein and albumin), esr is 4




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