response to discussion

RESPOND TO #2

Patients Information: 

J.S., 42-years-old, M, Caucasian 

Chief Complaint: “Back Pain”

HPI: Mr. Smith is a 42-year-old male who presents to the clinic today with lower back pain that has occured over the past month. Patient denies any recent trauma or falls. At times the pain radiates to his left leg and causes 6/10 pain upon ambulation. Patient describes his pain as shooting and throbbing at times depending on mobility. Taking Gabapentin 300 mg three times a day as well as ibuprofen 600 mg every 6 hours with no relief. Patient states he has been feeling depressed since the pain is not subsiding and that it is affecting him doing his job. 

Current Medications:

· Gabapentin 300 mg t.i.d. for back pain - started 8/21 

· Lisinopril 10 mg daily for HTN - started 3/19 

· Tylenol 1000 mg q6h for PRN pain relief 

· Ibuprofen 600 mg q6h PRN for pain relief 

Allergies: 

· Penicillin - Hives and itching 

· Cat Dander - Itching and watery eyes 

· Peanuts - Anaphylaxis 

Past Medical History: Mr. Smith was diagnosed with hypertension at the age of 39-years-old and is currently taking lisinopril daily. Patient states he is compliant with medications and takes no herbal supplements. Patient had a cholecystectomy in 2004 and rotator cuff surgery in 2008. All immunizations are up to date. Last tetanus was last year, in 2020, and the patient is fully vaccinated against COVID. Patient received a flu vaccination in September of this year. 

Social History: Mr. Smith is an electrician and states he has been working a lot of overtime as his wife just found out they are pregnant with their first child. She is 20 weeks pregnant. Patient states he used to smoke marijuana once a week but has stopped since the pregnancy was revealed. Patient denies any tobacco use or illicit drugs. Will have two beers a week with co-workers. Patient likes to golf with his brother twice a month and enjoys playing poker. Patient states he is very close with his parents and grandmother as they all live in the same neighborhood. He states his living condition is safe and denies any abuse. States wife has been supportive of helping around the house since the back pain started. Has insurance through his employer and has no concerns over affording medical costs.  Significant Family History: 

· Mother: DM2, HTN, Age 72       

· Father: HLD, HTN, Obesity. Age 75

· Maternal Grandmother: Died of colon cancer Age 80      

· Maternal Grandfather: Died of heart attack, Age 78      

· Paternal Grandmother: Breast Cancer, HTN, DM2, HLD, Age 93      

· Paternal Grandfather: Died of heart attack, Age 81      

· Brother: HTN, age 44

ROS:

· General: Denies fever and fatigue. 

· Neurological: Denies headache or dizziness 

· HEENT: Denies blurred vision or vision changes. Denies any hearing changes. No problems with swallowing. Denies any pain with neck ROM. 

· Respiratory: Denies any shortness of breath at rest and upon ambulation. Denies any coughing. 

· CV: Denies chest pain and any swelling in lower extremities. 

· GI: Denies nausea or vomiting. Has formed daily bowel movements. No abdominal pain. 

· GU: Denies frequency or urgency.

· Musculoskeletal: Pain to left leg and lower back upon ambulation. Difficult to bend over and has a hard time physically getting out of bed in the morning due to stiffness. 

· Psychiatric: Patient states he has been feeling sad and slightly depressed since pain is not improving and it is affecting his job. 

 

Objective Information: 

Vital Signs: 

· Height and Weight: 185 lbs, 5’10”

· Temperature: 37.2 C

· RR: 17

· HR: 89 BPM

· BP: 132/76

· pO2: 99% on RA

· General: No weight loss, fever, chills, weakness or fatigue. Facial grimace when asked to sit on exam table. 

· HEENT: Normocephalic. Eyes: No blurred vision, bilateral pupils 3+, brisk and round. No hearing loss, no nasal drainage or sore throat. Able to perform ROM to the neck without pain. Denies any loss or decreased sense of smell. No JVD. 

· Skin: Warm and diaphoretic. No rash or skin breakdown noted​​. 

· Cardiovascular: S1, S2. No murmur or gallop. NSR. Capillary refill less than 3 seconds to all extremities. No cyanosis noted. Mild trace edema present All pulses palpable and 2+. 

· Abdomen: Normoactive bowel sounds. Liver and spleen not palpable. No tenderness noted. Last BM was this morning. 

· Neurological: AOX4, Speech is clear. 

· Musculoskeletal: Lower back pain intermittently radiating left lower extremity. Pain is mainly in the thigh and calf. No evidence of trauma or swelling noted. Decreased mobility due to pain. Pain increases with extension, flexion and bending at the knee. 

Diagnostics: 

· CBC, BMP, ESR and CRP blood tests 

· Lumbar spinal X Ray - 2 view  

· CT of spine 

· MRI of spine

The nerve routes involved with the patient would be the lower spinal roots, L5 to S1. I would test the patient by performing a thorough spinal assessment.  I would assess Mr. Smiths sensory nerves by assessing dermatomes, specifically L1-S5. Sensation would be assessed by touching the specific areas L1-S5 communicate with with a sharp/dull object and have the patient recite back to me what they are feeling. I would also assess temperature and vibration senses with a tuning fork. All will be performed while the patient's eyes are closed. I would assess the patient's knee jerk to assess nerve pathways. Additional testing will include the Straight Leg Raise (SLR) test. The SLR test is a neurological maneuver that is performed while the patient is in a supine position and the examiner gently raises the patient's leg by flexing the hip with the knee in extension (Willhuber, 2021).  Pain stemming from the nerve routes from L5 to S1 will occur during leg straightening and will be relieved with flexion of the knee. Other symptoms that need to be explored are muscle spasms, numbness, pain that is constant and will not go away and fevers. Fever can mean the presence of a possible spinal abscess. Loss of bladder control must be closely watched as lower spinal complications can affect urination. 

 

Differential diagnosis for acute low back pain are: 

· Sciatica 

. Sciatica is a diagnosis based upon symptoms that include radiating pain down one leg with or without neurological deficits upon examination (Jensen et al., 2019). Imaging is not required to confirm the diagnosis of sciatica but only when the pain persists for more than 12 weeks or neurological deficits occur. Unilateral pain is a big indicator for this diagnosis. 

· Acute Disc Herniation

. Lumbar disc herniation is responsible for 85% of all cases of lower back pain, with patients being predominantly aged 40 to 50 years old (Belsuzarri et al., 2020). Patients with this diagnosis will present with significant lumbar and sciatica pain. The pain will radiate from the lower back area to either one or both legs and can be worse upon ambulation, as we see presented in our patient. 

· Lumbar Strain

. A strain in the lumbar region can cause lower back pain, spasms that can result in worsening pain and lower back pain that is sensitive to touch. Strain may be in place due to the patient's line of work. Too much stress to the lower back can cause a soft tissue injury and stretching of ligaments. Risk factors for lumbar strain include increased physical demands at work, age, depression and smoking (Branham, 2016). 

· Osteoarthritis 

. Osteoarthritis pain is usually treated with NSAIDs and Tylenol with some relief. Our patient has consistently been taking both with pain still present. Although that is the situation, osteoarthritis should still not be ruled out. This diagnosis includes stiffness, increased pain with activities and increased swelling and inflammation. 

· Ankylosing Spondylite

. This diagnosis is a chronic inflammatory autoimmune disease that mainly affects the joints of the spine, causing severe and chronic pain (Zhu et al., 2019). Mr. Smith could be suffering from an early onset of such diagnosis. Symptoms can appear in early adulthood and can be brought on by lower back pain. It can cause an increased amount of pain in the morning, due to morning stiffness, which our patient is currently complaining of. 

 

References

Belsuzarri, T., Barletta, E., Urena, A., Paz, D., Sparapani , F., Onishi, F., Cavalheiro, S., Salati, T., Benites, V., Joaquim, A., & Iunes, E. (2020). The natural history of patients with acute disc herniation: A series of 150 cases. Coluna/Columna, 19(2), 116–119. https://doi.org/10.1590/s1808-185120201902224169 

Branham, K. M. (2016). Lumbar Strain and Sprain. Physical Therapy: Treatment of Common. Orthopedic Conditions, 2(8), 214-45.

Jensen, R. K., Kongsted, A., Kjaer, P., & Koes, B. (2019). Diagnosis and treatment of sciatica. BMJ, l6273. https://doi.org/10.1136/bmj.l6273 

Willhuber, G. O. C. (2021, July 31). Straight leg raise test. StatPearls [Internet]. Retrieved October 19, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK539717/. 

Zhu, W., He, X., Cheng, K., Zhang, L., Chen, D., Wang, X., Qiu, G., Cao, X., & Weng, X. (2019, August 5). Ankylosing spondylitis: Etiology, pathogenesis, and treatments. Nature News. Retrieved October 19, 2021, from https://www.nature.com/articles/s41413-019-0057-8.