Pfff.... kidney stones seem to be the least zebra Dx right know... Lisinopril, recurring but increasing severity, palpation or striking causes increase in pain, and increased activity causes pain.... reduced hydration has reduced volume, 'bad' water increases mineralization coupled with the lisinopril and the attendant hyperkalemia...

Tell Top he needs to drink more water dammit, especially with lisinopril and heavy physical activity.

the other Dx option is gouty arthritis in combination with arthroarthritis in the lumbosacral joint (multiple damage does not r/o this area even though it is not an initial joint for attacks in most cases) - same reasons as above - need to get the diff on them and run a couple of blood panels... K levels and Uric acid levels will be key in the r/o on this... but it's gonna suck with no lithotripsy available for relief if it is a stone....

I'd like to go back to the Hx for a minute. Patient said he does weight lifting. Deadlifts? When was the last time he was at the gym? What was the routine? Weight? Did he increase the weight during the last workout? Did he notice any back pain during the workout? Immediately after?

Did the patient do clean-and-jerk or standing overhead presses in the last workout?

Last gym trip was a few days before deployment. He did dead lifts and squats as is normal for him, without any unusual increases in weight. He did not notice any pain during or immediately following the workout, and a number of days passed before he first noticed any symptoms (based on our hypothetical timeline, you've been in theater a week, and he noticed symptoms a few days in.)

Yep, if I were the Team Medic I would evac him to a facility that can take a peak (X-ray/MRI). I'm thinking herniated disc, vertebral process avulsion fracture, R/O kidney stones.

Before we start trying to nail our differential, I think it would help to complete our history and physical exams, and maybe do a problem list.

Nearest facility is a few hours away, and the trip will seriously disrupt training. Still wanna go?

300F-1, San Antonio, The 2005 reclass.... CPT Rocky Farr.... "We're going to work on your ability to get a good Hx, and diagnose to a diff Dx level wit h4 options.... 30y/o white male in good health (soldier) and normal vitals presents c/o black tarry stools x 1 wk.... Start asking, raise your hands...." every zebra in the world came running.... but I learned how to hit the easy hx questions early, and start with easy Dx for r/o...:rolleyes:

Just throwing that out there as a reminder.

Advise him to avoid 200+ pound snatch. :D

We are thinking the same, Bro. ;)

nah, not making the flour comment.....;)

Yep ;)

Full Vitals: (not yet asked... you only asked for BP and HR)
HR: 90, BP 130/85, RR 14, T 101.5deg

PMH (also not yet asked):
The patient's past medical history is significant for HTN. The patient had all routine immunizations and started malaria prophylaxis just prior to deployment. The patient was dental cat3 and had to have some significant work done to get off the "non-deployable" list before you left. No surgeries.

Oweee! Now that's a visual image I did not need. Thanks a lot Doc. :D