A case of back pain

Clinical Summary

53-year-old male with a history significant for marijuana use and hypertension presents with back pain that started 16 hours before arrival. The pain began while on the toilet and is described as sharp and constant, rated 10 out of 10.

Associated Symptoms:

• Occasional abdominal pain
• Occasional radiating lower chest pain
• Nausea and vomiting

The patient reports that hot showers help relieve the pain. He has taken four Excedrin migraine tablets without relief. Denies any other medical complaints, including shortness of breath or cough.

Previous Surgeries:

• Knee reconstruction
• Hip reconstruction

Medications:

• Does not take antihypertensive medication due to lack of energy.

Triage Vitals:

• Temperature: 37°C
• Heart Rate: 112 bpm
• Blood Pressure: 171/95 mmHg
• Respiratory Rate: 20 bpm
• O2 Saturation: 96% on Room Air

Physical Examination:

• General: Patient lying comfortably in bed, hands clasped, eyes closed, requesting pain relief.
• Cardiovascular: Tachycardia, no murmurs, no edema, equal pulses.
• Pulmonary: Clear to auscultation, mild expiratory wheezing.
• Gastrointestinal: Soft, non-tender.
• Musculoskeletal: Reproducible tenderness over paraspinal back; normal sensation, motor strength, and reflexes in lower extremities.

Additional Notes:

• EKG and 1 view XR obtained due to reported chest pain.

Questions for Consideration:

• What is your initial differential diagnosis?
• What additional questions would you ask or actions would you take?

Considerations:

This case occurs in a free-standing ED with access to CT imaging and point-of-care ultrasound, but limited medications are available.