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Back pain askmyGP report – what would you do?

Chief Complaint

Neil G is a 67 year old male. The “Back pain” screening questionnaire was administered. The following are his responses.

History of Present Illness

#1. “Back pain”

Context

He reported: First consult for back pain.

Past, Family, and Social History

Environmental Hazards

He denied: Upper back pain associated with extended amount of time spent typing at keyboard.

Review of Systems

Constitutional

He denied: Fever in the last week.

Genitourinary

He denied: Pain in side.

Musculoskeletal

He reported: Back pain began after coming to a sudden stop. Back pain moves around the chest or abdomen.

He denied: Swelling of the neck, arm, or hand.

Thoracic Spine and Ribs

He reported: Upper back pain 5 to 6 days, sharp, starting gradually and worsening over days, and severe (7-8/10) today.

Upper back pain sometimes brought on by a specific event. No prior episodes of similar upper back pain. Upper back pain sometimes associated with changes in humidity and nausea. Upper back pain comes and goes. Injury may have preceded upper back pain.

He denied: Upper back pain associated with chest pain. Upper back pain occurs at night. Stomach pain goes to upper back.

Neurologic

He reported: Loss of feeling in the right upper arm sometimes, in the right forearm sometimes, and same In all fingers of the right hand. Numbness or tingling in arms, legs or face. Mild loss of feeling in right hand.

He denied: Loss of feeling of hands occurs around lips also, in the leg, and in the face.

Psychiatric

Anxiety Disorders

He denied: Felt nervous, anxious, or under stress.

GPs, what would you do first?

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