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medical
D: And what brings you to the emergency department today? | |
P: Low back pain. | |
D: OK, and where exactly is uh is the back pain? | |
P: So the pain's just right in the in the lower back. | |
D: Just in the lower back, OK. And when did this pain start? | |
P: It started yesterday, I was unloading groceries from my pickup truck when it suddenly started. | |
D: OK, so, and, did you kind of make any kind of movement? Or did you pick up something really heavy? | |
P: I'm not sure. I just noticed the pain after um after that. | |
D: OK, and what kind of pain are you experiencing? Is it like a dull cramping pain or is it more like a sharp or stabbing pain? | |
P: It feels like it's stabbing just right in my lower back. | |
D: OK. And, um, on a scale of 1 to 10, uh 1 being like the least pain that you felt in your life, 10 being the worst, how much would you rate this pain? | |
P: If I'm sitting, uh completely still like like I am right now, it's a 2 out of 10. | |
D: OK. Um and when does it get worse? | |
P: Uh anytime I I move or bend my back or uh even cough it it worsens the pain significantly. | |
D: OK, and has this pain changed at all since yesterday? | |
P: No, it's been this same awful pain this whole time. | |
D: OK and have have you ever had this kind of pain before? | |
P: I've had back pain uh over the years, but nothing like this before. | |
D: OK. And does it, does the pain go anywhere or does it just stay in the lower back? | |
P: I also feel the pain uh into my right leg. | |
D: OK, and is it the same kind of aching or like stabbing pain that goes into your right leg? Or is it uh just like an aching pain? | |
P: Uh it's it's a, uh, an aching pain. | |
D: OK. And do you have any other symptoms besides the pain? Like are you experiencing any kind of weakness or any kind of, any other changes in your health? | |
P: Uh no it's just the uh the low back pain. | |
D: OK, and have you ever uh experienced any kind of trauma to your back? Like something has hit you or you've fall down, anything like that? | |
P: No, I can't remember any injuries like that in the past. | |
D: OK, any uh fevers or chills or night sweats? | |
P: Um no fever, uh no chills, no night sweats. | |
D: OK, any uh symptoms of feeling very tired, fatigued, anything like that? | |
P: Uh no, I've been OK recently. | |
D: OK. Any changes to your skin at all? Uh I mean, any rashes? | |
P: No. | |
D: OK, any pain in your joints at all? | |
P: Uh just the back pain. | |
D: OK. Uh any new coughs or any um symptoms and runny nose or anything like that? | |
P: Uh no. | |
D: Any changes in your um bowel movements at all like diarrhea, constipation or anything? | |
P: Nothing like that, been regular. | |
D: OK, how about, uh, any urinary problems? | |
P: Uh no, nothing to report there. | |
D: OK, and how has your appetite been? | |
P: Uh appetite's been normal. | |
D: Any significant weight loss or weight gain recently? | |
P: No, the weight's been about the same. | |
D: OK, any recent infections that you know of? | |
P: No, I've been feeling well otherwise. | |
D: OK. Any uh tingling sensation or numbness uh in your back or lower limbs, in your legs? | |
P: Uh no numbness or tingling. | |
D: OK. Any muscle weakness at all? | |
P: Uh no muscle weakness. | |
D: OK, have you been uh having any uh kind of erectile dysfunction? | |
P: Uh no concerns with uh erectile dysfunction. | |
D: OK, and any issues with uh incontinence, like uh having accidents at all, at night or during the day? | |
P: Uh no, I haven't had any problems with bowel or bladder incontinence. | |
D: OK, alright, and in terms of your past medical history, have you have you been diagnosed with any conditions like high blood pressure, diabetes? | |
P: Uh type 2 diabetes. | |
D: OK, and do you take any medications for it? | |
P: Uh I, um insulin for diabetes. | |
D: OK, and any other medications at all? | |
P: Uh just been taking Tylenol for the the back pain. | |
D: And has that worked for you at all? Or has it not made a difference? | |
P: Uh maybe it's taking the edge off a little bit, but it hasn't done too much uh to help the pain. | |
D: OK, any allergies? | |
P: Uh nope. | |
D: OK. Any previous surgeries? | |
P: Uh I had hemorrhoids removed three years ago. | |
D: OK. Um any hospitalizations before? | |
P: Uh no, it was just day surgery, | |
D: OK, any family history of any um conditions uh or like any cancers? | |
P: Uh my father had prostate cancer. | |
D: OK. And currently right now, uh do you work? | |
P: Uh I'm a retired school teacher. | |
D: OK, and where do you live? | |
P: I live alone um in a in a house uh not too far from here, actually. | |
D: OK. And do you do you drink at all? | |
P: Um occasionally uh maybe I'll have a glass of red wine on the weekend or something like that, but uh not too often. | |
D: OK, and do you smoke? | |
P: Uh, I've smoked um yeah, I smoke a pack of cigarettes uh per day. | |
D: OK, and for how long have you smoked uh cigarettes for? | |
P: Uh about 40 years. | |
D: 40 years, OK. And, uh, do you use any kind of recreational drugs? | |
P: Uh never. | |
D: OK, and how is your diet like on like a regular basis? | |
P: I feel like it's uh pretty normal, mostly home cooked meals with some variety, vegetable, vegetables, other meats, and fish. I would say it's pretty balanced. | |
D: OK, alright, I just have a few more questions for you. Um are you currently sexually active? | |
P: Yes, I am. | |
D: OK and who are you sexually active with, any new partners at all? | |
P: Uh no new partners, um just my girlfriend, uh. | |
D: And, uh, how many, I'm sorry, go ahead. | |
P: Um just my my girlfriend recently. | |
D: OK, and have you been sexually active with more than one partner in the past, past year? | |
P: Uh yes, I have, um um two women over the past year. | |
D: OK, and um do you use any kind of protection? | |
P: Yes, always use uh condoms. | |
D: OK. Alright, so now I'm just going to get the patient's vitals. |