Case 21: Introduction

History of Present Illness (HPI)

clipboardA 75 year old man with a history of well-controlled hypertension presents to his primary care physician with fatigue and back pain for the last 2-3 weeks. He has had episodes of back pain in the past, but says that this is worse.

He does not report and heavy lifting or trauma and says that the pain is constant throughout the day, not relieved with ibuprofen which has taken intermittently. No fevers, chills, nausea, vomiting, night sweats, chest pain, shortness of breath, or abdominal pain. He reports some swelling of his legs that is new. He has no numbness or tingling of his extremities. He has not noticed hematuria or or other changes in his urine or urinary habits.

He lives at home with his partner and dog. He drinks one glass of wine daily and does not use tobacco or illicit drugs.  In addition to recent ibuprofen use, his daily medications are hydrochlorothiazide 25 mg daily and atenolol 10 mg daily.

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