History of present illness

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Reference no: EM133779639

Question: Synchronous Evaluation of a Standardized Patient Chief Concern: 60-year with acute low back pain for 5 days. History of Present Illness: Back pain started as dull and achy following a low fall after missing a step. Felt like "something was pulled" so waited it out. Rested the first day, took ibuprofen 600 mg twice a day since day 4. Pain was dull and achy localized to low back initially now occasionally sharp with movement. Strange deep tingling sense down left buttock around hip to top of thigh now. Trouble sleeping due to discomfort, limited movement and some difficulty with activities around the house. No changes in bowel or bladder. No tingling or changes in sensation in feet. Two back injuries in the past, one from car accident at age 50 and a martial arts injury age 28. PMH: Chronic low back pain mild herniation from car accident & martial arts injury, high cholesterol x 7 years, osteoarthritis x 5 years FMH: Father, passed away from Myocardial Infarction (MI), Mother passed away of old age, Paternal side with stroke & MI, Cirrhosis. Meds: Atorvastatin 20 mg one tab daily Celebrex 100 mg one tab daily as needed for pain, use sparingly

Reference no: EM133779639

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