Back Pain Advanced Health Assessment

Back Pain Advanced Health Assessment

Back Pain Advanced Health Assessment

A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?

Patient Information:

M.S. Age 42 Caucasian Male

S.

CC: “Lower Back Pain”

HPI: The patient is a 42-year-old white male who developed lower back pain for 1 month. He states the pain radiates to his left leg. His lower back pain is increased with sitting for long periods of time, states the pain gets better when stands and with some Tylenol. Denies any fever, chills, and sweating.

Current Medications: Tylenol 200 mg two every 4 to 6 hours as needed for pain.

Allergies: No known drug, food, or environmental allergies.

PMHx: None Up to date on all immunizations, received flu shot this year. Last tetanus shot 1 years ago.

PSHx: none

Soc Hx: M.S. is a retired plumber who lives alone. He enjoys activity such as walking, bike riding and camping outdoors. Nonsmoker, social drinker 3-4 beers on the weekends, denies illegal drug use. Back Pain Advanced Health Assessment

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Personal/Social History: Patient denies ever smoking cigarette. Denies any recreational drug use.

Fam Hx: Mother alive, age 72-years-old, breast cancer at age 52 in remission. Father died at age 70 (2yrs ago) – history of CAD, MI age 70 died. Maternal grandmother: Hypertension, breast cancer. Maternal grandfather: Hypertension, BPH, GERD, atrial fibrillation, hyperlipidemia, CHF, AICD. Paternal grandmother: Unknown history

Paternal grandfather: Hypertension, CKD, GERD, BPH, COPD, asthma.

ROS:

GENERAL: No weight loss. Complaint of lower back pain. No complaint of fever, chills, weakness, fatigue, constipation, bladder, or bowel incontinent.

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: No Complaint of sob, no cough.

GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or bowel incontinent, no rectal pain or bleeding

GENITOURINARY: No difficulty with urination, no urinary leakage or incontinence.

NEUROLOGICAL: No headache, no dizziness, no syncope, no paralysis, no ataxia, no numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: complaints of lower back pain radiate to back of right leg. Pain 8/10, sometimes increase pain when turning in bed, walks with limp when having pain. Patient reports a lower back for one-month, intermittent pain when ambulating that shoots down the right, lateral thigh, down to the knee, and no numbness of leg. The patient states his pain is relieved somewhat with his OTC Tylenol. Patient denies any swelling, redness, or heat at any of the joint sites.

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlarged nodes in the groin. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No complaints of fever, chills, and sweating.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam:

VS: BP 140/76; P 82; R 19; T 97.7F; O2 SAT 99%; Wt. 200 lbs.; Ht 6’8”, pain 8/10 on scale of 0-10 at rest

General: 42-yr-old Patient presents as a well-developed, young adult Caucasian who appears his stated age. He is alert, oriented, and cooperative. The patient walks with slight limp,

HEENT: normocephalic head with normal distribution of hair. No facial tenderness to light sensation. Conjunctivae are pink with white sclera and without jaundice. PERLA, with pupils 3mm in size bilaterally. No exudates seen. Nasopharynx and pharynx without erythema, lesions, or exudates. Mucous membranes are moist. Upper and lower teeth in good condition and intact. The trachea is midline.

Neck: normal ROM, Supple with no JVD or bruits, there is no adenopathy. No swelling noted.

Chest/Lungs: Lungs are clear to auscultation anteriorly and posteriorly with equal symmetry of chest rise and fall. Resonance noted to percussion bilaterally. No wheezes, rhonchi or stridor.

Cardiovascular: RRR without murmur. Good S1, S2. Radial and pedal pulses +2 bilaterally. No abdominal, carotid, or femoral bruits. No JVD.

Peripheral vascular: No edema of extremities. 2+ palpable radial, posterior tibial, and dorsalis pedis pulses. Normal distribution of hair on lower extremities. Normal color. Capillary refill less than 3 seconds. No cyanosis or clubbing present.

Abdomen: Flat, soft NABS x4. non-tender, no inguinal nodes noted.

Genital/Rectal: Deferred.

Musculoskeletal: Symmetrical development of upper and lower extremity. No erythema or deformities of joints. Palpate pain noted at the right lower lumbar region. Pain to lower back when leg is extended while thigh if flexed when lying flat. Limited ROM of right leg with pain at 40 degrees when lifting. ROM limited to forward bending 10 inches from the floor. Pain to right buttock area and right posterior thigh with palpation. Minimal flexion of the right knee due to pain. No crepitus or stiffness to palpitation of joints. Other joints unremarkable.

Neurological: CN II-XII intact. DTRs 2+ lower extremity intact. Sensory neurology intact to light touch and patient able to toe and heel walk. Normal gait with ambulation and limping noted.

Skin: Warm and dry to touch. No ecchymosis or edema. No noted rashes, open wounds, or lesions. Hair is evenly distributed over scalp.

Diagnostic tests/labs:

a. Walk across the room to examine abnormalities in patient gait (pattern of walking)

b. Hip flexion and knee hyperextension up to 30 degrees. Bend or flex parts of your spine to assess spinal range of motion example bend forward)

c. Simply stand to identify any problems with balance, posture and/ spinal alignment

d. The femoral stretch test is used to detect inflammation of the nerve root at the L1, L2, L3 and L4

e. CBC: used to confirm the diagnosis of infection. Back Pain Advanced Health Assessment

f. Urinalysis to check for UTI.

g. XR lumbar spine

h. Plain-film X-ray provides 2 view of motion and evidence of trauma.

i. CT scanning: Detect abnormal tissue and the state of the patient’s spine.

j. MRI Lumbar spine: used to generate detailed images or slices of the spinal anatomy. MRI also can reveal the structure of soft tissues, such as the discs, spinal cord, and nerves. (Dains, J. E., Baumann, L. C., & Scheibel, P., 2016).

A.

Differential Diagnoses:

1. Lumbosacral Herniated Disc

2. Cauda Equina

3. Musculoskeletal Lumbar Strain

4. Acute Pyelonephritis,

5. Lumbar spinal stenosis

Lumbosacral Herniated Disc is the most appropriate diagnosis. The authors Kim et al., 2018, stated that “one person from eight suffers from degenerative disc disease, as well as from various joint diseases (arthrosis, arthritis, sciatica), the pain being in the medial or inferior part of the spine. At first, it is manifested as a slight redness, then pain occurs when walking or bending, and then gradually radiating to the leg, which can affect the individual life” (Kim et al.,2018). And my patient is exhibiting these symptoms.

Lumbosacral Herniated Disc (Sciatica): According to Ball et al., 2015 Herniated disc disease usually caused by degenerative changes in the disc. The most common sources of back pain are abnormally changed discs, facet and sacroiliac joints, and muscles; however, it is often difficult to determine the main source of pain. The nerve root generally involves occurs at L4, L5 and S1 nerve roots. This patient is at greater risk because of his age group and may involve trauma because this patient occupation as a plumber.

According to Koes, Van-Tulder and Peul 2007 “other symptoms that need to be explored are unilateral leg pain greater than low back pain, Pain radiating to foot or toes, numbness and paranesthesia in the same distribution, straight leg raising test induces more leg pain, localized neurology changes that involves L4, L5 and S1 that which is to limit one nerve root” (Koes., van Tulder., & Peul, 2007).

Cauda Equina: According to Dains, Baumann and Scheibel 2016, “Cauda Equina compression of S1 nerve root produce continuous lower back pain with saddle distribution of anesthesia. The patient will present with symptom include lower back pain, unilateral or bilateral sciatica nerve pain, bowel, and bladder disturbances generally present with BB incontinence, lower extremity motor weakness with limping, sensory losses or deficits in the lower extremity and reduced or absent lower extremity reflexes” (Dains, J. Baumann, L. & Scheibel, P. 2016). I choose it because my patient is presenting with some of the symptoms.

Musculoskeletal Lumbar Strain: Lumbar strain is based on history and clinical findings. A complete history may suggest the cause of acute lower back pain based on the type of injury the patient sustained (Lupu., A.,2017). If the patient present with no history of trauma or no history of strenuous physical activities, then the likely diagnosis of Lumbar strain is evident. According to Dains, Baumann and Scheibel 2016 “muscles in the back can become inflamed from over usage of muscles and ligaments. Patient report that rest will alleviate pain and with treatment of heat or cold therapy” (Dains, J. E., Baumann, L. C., & Scheibel, P., 2016).

Acute Pyelonephritis: The range of acute pyelonephritis is wide, from a mild illness to sepsis. According to Dains, Baumann and Scheibel 2016, “patients may appear very ill and diaphoretic with symptoms of nausea, vomiting, headache, and back or flank pain” (Dains, J. E., Baumann, L. C., & Scheibel, P., 2016). To diagnose acute pyelonephritis, the practitioner must rely on evidence of UTI from urinalysis or culture, along with signs and symptoms suggesting upper UTI (fever, chills, flank pain, nausea, vomiting, costovertebral angle tenderness). Symptoms that are suggestive of cystitis (dysuria, urinary bladder frequency and urgency, and suprapubic pain) also may be present.

Lumbar spinal stenosis – Lumbar spinal stenosis (LSS) is a disease in which degenerated discs, ligamentum flavum, facet joints, while aging, lead to a narrowing of the space around the neurovascular structures of the spine (Fishchenko et al., 2018). Symptoms may be due to inflammation or compression of the nerve and include pain and weakness or numbness in the legs. There is no ‘gold standard’ for diagnosis of LSS; the diagnosis is based on a combination of factors including history, physical examination, and imaging studies. Assessment should focus on leg or buttock pain while walking, flex forward to relieve symptoms, feel relief when using a shopping cart or a bicycle, motor or sensory disturbance while walking, pulses in the foot present and symmetric, and lower extremity weakness (Chagnas et al., 2019). Imagining can be used to determine if there is any inflammation, and when surgery is becoming imminent. Back Pain Advanced Health Assessment

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Koes, B. W., van Tulder, M. W., & Peul, W. C. (2007). Diagnosis and treatment of sciatica. BMJ: British Medical Journal, 334(7607), 1313–1317. http://doi.org/10.1136/bmj.39223.428495.BE

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