Reference no: EM133365643
Assignment:
History of Present Illness
A 68-year-old man presents to his PCP with a 1-week history of thoracic pain. He describes the pain as slow onset of symptoms on the right side of his thoracic spine radiating to his anterior trunk. The pain has progressively worsened, and he describes it as sharp and burning. He states the discomfort started a week ago as an ache after returning from work. He suspected a strained muscle and treated with warm packs and over-the-counter ibuprofen. In the subsequent days, his pain became worse, and he was concerned he had irreversibly injured his back. He denies any associated paresthesia or recent weight loss.
About 2 days ago, he noticed a mildly pruritic rash to his abdomen, and he was not sure if this was related to his pain. He states, "It even hurts to breathe now," noting that positional changes make the pain worse. He states it is very tender to lay on his right side.
He is a fieldworker; he drives heavy equipment and supervises other workers. He is concerned he injured his back getting in or out of equipment, which occurs frequently during a normal workday.
Review of Systems
A ROS is positive for difficulty sleeping related to right upper abdominal pain, fatigue, mild dyspepsia, decreased appetite, and mild dyspnea on exertion related to pain. The ROS is negative for fever, chills, cough, vomiting, sick contacts, melena, hematochezia, liver disease, HIV, headache, dizziness, blurred vision, recent travel requiring prolonged sitting, paroxysmal nocturnal dyspnea, lower extremity, palpitations, paresthesia, or muscle weakness.
Relevant History
The patient's medical history is significant for well-controlled type 2 diabetes, hypertension, hyperlipidemia, and obesity. His surgical history is significant for cholecystectomy (age 48), colonoscopy, and upper endoscopy (age 65) revealing mild gastritis. He admits to usual childhood illnesses. Social history is significant for one to two beers after work daily. The patient quit smoking cigarettes at age 48 and denies recreational drug use. He is heterosexual with no history of sexually transmitted infections and enjoys a monogamous relationship with his wife. He has three grown children, nine grandchildren, and one great grandson. He resides in a single-story home with his wife. He is the primary wage earner. He states a granddaughter is reliant on him for college funding. His family history is unknown.
Allergies
No known drug allergies; no known food allergies.
Medications
Metformin 1,000 mg PO BID.
Glargine insulin 15 units SQ QD.
Atorvastatin 20 mg QD.
Lisinopril 20 mg PO QD.
Aspirin 81 mg PO QD.
Fish oil (omega 3) 1,000 mg PO QD.
Physical Examination
Vitals: T 37°C (98.6°F), P 88, R 14, BP 138/82, WT 85 kg (188 lbs), HT 170 cm (67 in.), BMI 29.
General: Spanish-speaking male. Grimacing and appears in pain with guarded movements.
Psychiatric: Good historian with linear thought processes.
Skin, Hair, and Nails: Right sub-xiphoid area with 1- to 2cm papular vesicular rash on background of hyperemia in clusters, extending laterally to midclavicular line in dermatomal pattern. Few dispersed vesicles noted. No lymphadenopathy to axilla. No other lesions or rashes noted. Hair and nails unremarkable. Hair present to lower extremities and dorsum feet, with even distribution bilaterally.
Head: Normocephalic, atraumatic.
Eyes: PERRLA, EOMI.
ENT/Mouth: Dentition in good repair. Gross hearing intact. Bilateral TMs patent.
Neck: FROM, trachea midline, no adenopathy.
Chest: Symmetrical, no axillary adenopathy.
Lungs: Clear to auscultation bilaterally. Good air movement discernible.
Heart: RRR, without murmur/gallop.
Back: No spinous tenderness. Right back tender to touch at approximately T7; inferior angle of scapula level. FROM neck with flexion, extension, lateral and rotational movements. FROM left and right shoulder without scapular winging.
Abdomen: Protuberant. Moderate tenderness right upper quadrant and epigastric area to light touch. No peritoneal signs. No ascites. Murphy sign negative. Negative rebound.
Neurologic: Cranial nerves II to XII intact. Hyperesthesia right T7 to T8 dermatomes; otherwise normal gross motor sensation in upper and lower extremities.
1. What is the differential diagnosis?
2. What is the most likely diagnosis? Why?
3. What are the next appropriate steps in management?