FA, 42-year-old Caucasian male
CC “Lowest back pain for the past month”
HPI: FA is a 42-year-old Caucasian male who presents to the clinic due to lower back pain that c has been ongoing for the past one month. FA stated that his pain started after attempting to lift a heavy table in his home from one part of the house to another one month ago. Patient reports that resting and taking Ibuprofen to reduce the pain, while his pain increases with activity. FA rates his pain at 5 on the 0-10 pain scale, as aching/dull that radiates to her left leg intermittently.
Current medications Ibuprofen 600mg as needed for pain.
Allergies: Denies any allergy.
PMHx: Up to date to immunization. Last influenza and pneumonia vaccine was November 2019. No past medical history noted. No previous hospitalization or blood transfusion.
Soc Hx: FA owns a local car repair shop. He is married with 2 young kids 10 and 8 years old. Patient is deeply involved in the local catholic church and is a choir master. Denies use of illicit drug and tobacco. States he is a social drink and consumes 2-3 beer weekly. Exercises regularly.
Fam Hx: Father, Alive 72, HTN.
Mother, Alive 68 Diabetes.
Paternal Grandfather: HTN, deceased at age 78 from stroke.
Paternal Grandmother: Alive, 95, Anxiety.
Maternal Grandfather: Alive, 93 HTN, Hyperlipidemia.
Paternal Grandmother: Alive, 88 Type 11 diabetes (controlled with diet).
Daughter: No medical history, age 10.
Son: No medical history, age 8.
General: Pt denies fever and fatigue. Denies weight loss.
Neurological: Pt headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
HEET: Eyes: T denies visual changes. Ears: denies hearing loss. Nose: Denies rhinorrhea. No hearing loss. Sneezing, runny nose or sore throat.
Throat: Denies sore throat.
Skin: Pt denies rash, abrasions, or bruising denies rash.
Cardiovascular: Pt denies chest pain, chest pressure or chest discomfort. palpitation, and tachycardia.
Respiratory: Pt denies SOB, Cough congestion or congestion. Respiratory:
Musculoskeletal: Reports aching/dull lower back pain. Reports a limited range of motion with bending. Pain occasionally radiated to left leg.
Diagnostic results: Vitals: T: 98.0, HR: 78, RR: 18, BP: 128/70, O2sat: 98% on RA. Pain 5/10
General: Pt is AAOx4. Well-groomed male calm and cooperative Able to communicate fluently, with a good eye contact. Appears in no acute distress.
Neurological: No signs of dizziness, no problems with gait or posture noted. 4/5 strength with dorsiflexion and toe extension in LLE. 5/5 strength with dorsiflexion and toe extension in RLE. No decreased sensation to BUE and BLE.
HEENT: EOMI, PERRLA, pupil round and reactive to light, moist mucus membrane noted. No head injury noted, oral mucosa dry.
Skin: No edema noted on extremities No abrasions, and cyanosis. Skin taut, non-tenting, and atraumatic.
Cardiovascular: S1, S2 noted with a regular rhythm. No murmur, gallops, or extra heart sounds.
Respiratory: Lungs sound clear on auscultation. No adventitious breath sounds noted.
Musculoskeletal: No scoliosis noted. Negative Sciatic Nerve, Negative Mackiewicz sign in bilateral lower extremifies. Negative Lasegue’s sign in left lower extremity. Pain noted on palpation of L5. Patellar reflex 2+ bilaterally. Full range of motion in torso extension and lateral flexion. Limited range of motion with flexion and lateral rotation of torso related to pain.
Primary Diagnosis: Lumbosacral Radiculopathy
Lumbosacral radiculopathy (Disc herniation): describes the types of pain caused by compression or irritation of nerve roots in the lower back, caused by lumbar disc herniation, degeneration of the spinal vertebra, and narrowing of the foramen from which the nerves exit the spinal canal. L5 is the most common injury in the lumbar spine (Hsu, Armon, & Levin, 2019). An L5 disc herniation typically presents as back pain that radiates to the leg and foot (Hsu et al., 2019). In a disc herniation, the nerve root becomes compressed from cancer, infection, injuries from falls (Hsu et al., 2019). The straight leg test is the most helpful assessment tool when assessing for a disc herniation (Hsu et al., 2019). A magnetic resonance imaging (MRI) scan is used to diagnose a disc herniation by evaluating the intraspinal spaces for abnormalities (Hsu et al., 2019).
Vertebral Osteomyelitis: is a bone infection usually caused by bacteria. In the spine, it is often found in the vertebrae, although the infection can spread into the epidural and intervertebral disc spaces. Osteomyelitis is rare and most common in young children and the elderly, but it can occur at any age (McDonald & Peel, 2019). The infection to the bone could result from surgery or other soft tissue infection (McDonald & Peel, 2019). Symptoms include pain localized to the disc that is infected and is aggravated with palpitation or physical activity (McDonald & Peel, 2019). A computerized axial tomography (CT scan) is used to diagnose Vertebral Osteomyelitis, using a guided biopsy of the vertebral disc space to culture the bacteria (McDonald & Peel, 2019). Treatments of Vertebral Osteomyelitis include antibiotic therapy for six weeks (Roblot et al., 2007).
Paraspinal muscle strain: Is defined as over stretch injury or tear of paraspinal muscles and tendons in the low back. Muscle strains are common injury (Patricios, 2019). Overstretching of a muscle leads to a small tear in the tissue causing a strain (Crowley, n.d.). To assess for such muscle strain is by asking about trauma to the painful area (Patricios, 2019). Symptoms include sudden lower back pain, muscle spasms, inflammation, bruising, and soreness (Crowley, n.d.). Most times, treatment is not needed or treatments with rest, ice, pain medication and physical therapy (Cooper, 1993).
Piriformis syndrome: Piriformis syndrome is a condition in which the piriformis muscle, located in the buttock region, spasms and causes buttock pain. The piriformis muscle can also irritate the nearby sciatic nerve and cause pain, numbness and tingling along the back of the leg and into the foot (like sciatic pain). Piriformis syndrome is marked by hip and gluteal pain (Boyajian-O’Neill, McClain, Coleman, & Thomas, 2008). Clinical manifestations include acute back pain for less than four weeks (Wheeler, Wipf, Staiger, Deyo, & Jarvik, 2019). Symptoms includes worsened pain after sitting down for about 15 minutes (Boyajian-O’Neill et al., 2008). Assessments includes inspecting the back and posture, palpating the spine, performing the straight leg test, and assessing psychological distress (Waddell’s sign) (Wheeler et al., 2019). Diagnoses are made through electromyography (EMG) by differentiating between piriformis syndrome versus disc herniation (Boyajian-O’Neill et al., 2008).
Lumbar Stenosis: The lumbar spine consists of five vertebrae in the lower part of the spine, between the ribs and the pelvis. Lumbar spinal stenosis is a narrowing of the spinal canal, compressing the nerves traveling through the lower back into the legs. (Ball, Dains, Flynn, Solomon, & Stewart, 2019). Symptoms include pain with activities, such as walking or standing. The pain from Lumbar Stenosis radiates down the leg, slight relief in a sitting position, and increased pain with prolonged standing/walking (Ball et al., 2019). To assess, the patient exhibits a forward gait and lower extremity weakness in progressing lumbar stenosis (Ball et al., 2019). To diagnose, a radiology imaging (X-ray), CT scan, and an MRI are used (American Association of Neurological Surgeons [AANS], n.d.).
According to the scenario presented, the probable nerve that are involved are L4-S1. The cause could also be from lumbar two, three, and four (L2,3,4) (Ball, Dains, Flynn, Solomon, & Stewart, 2019). The straight leg test is used to test for L4-S1 abnormalities (Standford Medicine 25, n.d.). The femoral stretch test is used to test for L2,3,4 abnormalities (Mackiewicz sign). Also, using the patient’s history, such as pain onset, location, duration, character, aggravating and relieving factors could help in diagnoses (Ball et al., 2019). I chose these 5-differential diagnosis, disc herniation, vertebral osteomyelitis, lumbar stenosis, paraspinal muscle strain, and piriformis syndrome. The assessment and diagnosis of the lower back pain should involve examination of gait, posture, range of motion, inspection, and palpation of the painful location (Bratton, 1999). Assessment should include asking the patient to bend forward in flexion, extension, lateral flexion, and lateral rotation to evaluate the range of motion and limitation (Bratton, 1999).
American Association of Neurological Surgeons. (n.d.). Lumbar spinal stenosis. Retrieved January 13, 2020, from https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Lumbar-Spinal-Stenosis
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Boyajian-O’Neill, L. A., McClain, R. L., Coleman, M. K., & Thomas, P. P. (2008). Diagnosis and management of Piriformis Syndrome: An osteopathic approach. The Journal of the American Osteopathic Association, 108, 657-664. Retrieved from https://jaoa.org/article.aspx?articleid=2093614
Bratton, R. L. (1999). Assessment and management of acute low back pain. American Family Physician, 60(8), 2299-2306. Retrieved from https://www.aafp.org/afp/1999/1115/p2299.html
Cooper, R. G. (1993). Understanding paraspinal muscle dysfunction in low back pain: A way forward? Annals of the Rheumatic Diseases, 52(6), 413. https://doi.org/10.1136/ard.52.6.413
Crowley, K. (n.d.). Patient education: Muscle strain (The Basics). Retrieved January 12, 2020, from https://www.uptodate.com/contents/muscle-strain-the-basics?search=back%20muscle%20strain&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H276646807
Engle, A. M., Chen, Y., Marascalchi, B., Wilkinson, I., Abrams, W. B., He, C., Yao, A. L., Adekoya, P., Cohen, Z. O., & Cohen, S. P. (2019). Lumbosacral Radiculopathy: Inciting Events and Their Association with Epidural Steroid Injection Outcomes. Pain Medicine, 20(12), 2360–2370. https://doi-org.ezp.waldenulibrary.org/10.1093/pm/pnz097
Hsu, P. S., Armon, C., & Levin, K. (2019). Acute lumbosacral radiculopathy: Pathophysiology, clinical features, and diagnosis. Retrieved January 12, 2020, from https://www.uptodate.com/contents/acute-lumbosacral-radiculopathy-pathophysiology-clinical-features-and-diagnosis?search=disc%20herniation&source=search_result&selectedTitle=1~101&usage_type=default&display_rank=1#H17
McDonald, M., & Peel, T. (2019). Vertebral osteomyelitis and discitis in adults. Retrieved January 12, 2020, from https://www.uptodate.com/contents/vertebral-osteomyelitis-and-discitis-in-adults?search=disc%20herniation&topicRef=5262&source=see_link#H1
Patricios, J. (2019). Adductor muscle and tendon injury. Retrieved January 12, 2020, from https://www.uptodate.com/contents/adductor-muscle-and-tendon-injury?search=paraspinal%20muscle%20strain&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H6959568
Roblot, F., Besnier, J. M., Juhel, L., Vidal, C., Ragot, S., Bastidies, F., … Godet, C. (2007). Optimal duration of antibiotic therapy in vertebral osteomyelitis. Seminars in Arthritis and Rheumatism, 36(5), 269-277. https://doi.org/10.1016/j.semarthrit.2006.09.004
Standford Medicine 25. (n.d.). Approach to the low back exam. Retrieved January 12, 2020, from https://stanfordmedicine25.stanford.edu/the25/BackExam.html
Wheeler, S. G., Wipf, J. E., Staiger, T. O., Deyo, R. A., & Jarvik, J. G. (2019). Evaluation of low back pain in adults. Retrieved January 13, 2020, from https://www.uptodate.com/contents/evaluation-of-low-back-pain-in-adults?search=piriformis%20syndrome&source=search_result&selectedTitle=4~29&usage_
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