CHIEF COMPLAINT: Left rib pain for the past 3 weeks.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male with a history of prostate cancer with metastases to the bone and colon, who comes in complaining of left lower rib pain for the last 3 weeks.
He denies any recent trauma. It is worse with activity. He denies any pain when he is at rest. He states that there is no pain on deep inspiration. It is reproducible on palpation. He denies any radiation.
He says that it is an 8/10 on a pain scale. No relief with over-the-counter NSAIDs. It is interfering with his work.
PAST MEDICAL HISTORY:
1. Prostate cancer.
2. Metastases to the bone.
3. Metastases to the colon.
CURRENT MEDICATIONS: Casodex.
ALLERGIES: None.
SOCIAL HISTORY: The patient denies any smoking, denies alcohol use and denies drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: No chest pain, shortness of breath, nausea, vomiting or diarrhea. No fever or chills. Left-sided rib pain is positive. All other review of systems negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: On presentation, temperature 98.4, blood pressure 144/58, pulse 78, respirations 18, pulse oximetry 99% on room air.
GENERAL: The patient was not appearing in any acute distress, well-nourished, awake, alert and oriented.
HEENT: Normocephalic, atraumatic. Pupils equal, round and reactive to light. Extraocular movements intact. Mucous membranes are moist.
NECK: Range of motion is 100% in all 4 directions.
CHEST: Clear to auscultation bilaterally. On palpation, he did have some mild tenderness in the left lower ribs, around rib 9, 10, and 11 on palpation.
HEART: Regular rate and rhythm. S1, S2, no murmurs appreciated.
ABDOMEN: Soft, nontender, nondistended. No organomegaly appreciated. Positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema. Pulses are palpable 2+ bilaterally.
LABORATORY DATA: WBC 5.0, hemoglobin 12.8, hematocrit 39.6, platelet count 169. Sodium 138, potassium 3.9, chloride 104, BUN 16, creatinine 1.1, glucose 168. Cardiac enzymes: CK 674, CK MB 2.9. Troponin I is less than 0.1.
X-RAY: X-ray was read as negative.
EKG: No changes from previous. No signs of injury or infarct.
EMERGENCY DEPARTMENT COURSE: The patient was evaluated, received morphine 4 mg IV for his pain control.
MEDICAL DECISION MAKING: This is a (XX)-year-old male who comes in complaining of left-sided rib pain. It was originally thought that maybe he had a rib fracture. X-rays were obtained which were read as negative, possible consideration for atypical chest pain. The EKG did not show any changes from previous, and the first set of cardiac enzymes was negative. It is currently felt that he has just exacerbated musculoskeletal pain. Bony metastases were not present on x-ray. So, he will be discharged home in stable condition with prescription for Vicodin 5/500, #30 pills.
IMPRESSION/DIAGNOSIS: Musculoskeletal pain.
PLAN:
1. The patient will be discharged in stable condition.
2. Prescription for Vicodin.
3. He is to follow up with the Hematology/Oncology physician in 1 week.
4. He is to return for any worsening of symptoms.
