Patient Initials: MP Subjective Data:The patient presents to the clinic with complaints of sharp, stabbing lower back pain that radiates down his left leg for the past 2 weeks. The patient states the pain initially started two weeks ago while he was lifting a box at work. For pain relief, he used an ice pack and took ibuprofen. The pain got better within the next 3 days. However, last weekend, while playing softball with his daughter, the pain came back worse than before. Patient states the pain is so bad and debilitating, that he is barely able to get out of med in the morning. The patient describes the pain as sharp and it radiates down his left leg to his ankle.
Chief Compliant: Mr. Payne states he is having “sharp and stabbing pain on the left side of his back” after he lifted a box 2 weeks ago. He states the pain got better after three days but it returned after playing softball. MP states his pain is causing him to have “trouble getting out of bed”.
History of Present Illness:MP is a 45-year-old Caucasian male who presents today in clinic complaining of lower back pain. Mr. Payne’s past medical history includes: well controlled diabetes, hypertension and hyperlipidemia both which are fairly-controlled.
Onset:2 weeks ago
Location: Lower back on the left side; radiates down left leg
Duration: Intermittent chronic back pain
Characteristics: Sharp and stabbing
Aggravating factors: Activity, lifting, sitting for a long period of time
Relieving factors: Pain is better when he lies down
Treatment: Ice, Ibuprofen, Naproxen
Severity: Patient describes severe lower back pain where he is unable to get out of bed. Patient states his pain is a 7 out of 10 on approved pain scales.
PMH/Medical/Surgical History:MP denies any surgical history or drug allergies. The patient’s medications include: Metformin 500mg 2 twice daily, Glyburide 5mg 2 twice daily, Amlodipine 2.5mg daily, Lisinopril 40mg daily, and Simvastatin 40mg daily.
Significant Family History: MP denies family history of inheritable diseases
Social History:Mr. Payne works as a truck driver and he lifts about 20 to 35 pounds about 4 hours during his work days. The patient states he is married and has 2 daughters. MP states that he quit smoking 2 years ago. He also admits to drinking 1 to 2 beers occasionally on the weekends. The patient denies IV drug use.
Review of Symptoms:
General:Denies fever, chills, weight loss, or recent trauma except for when he lifted a 10-pound box at work, unrelenting night pain.
Integumentary:Denies skin changes.
HEENT:Denies headache, vision changes, sore throat or trouble swallowing.
Cardiovascular:Denies chest pain, palpitations, edema, or shortness of breath.
Respiratory: Denies shortness of breath or cough.
Gastrointestinal:Denies nausea, vomiting, changes in bowel habits, or bowel incontinence.
Genitourinary:Denies dysuria, change in frequency, or problems with bladder control.
Musculoskeletal:Admits to low back pain which radiates down his left leg.
Neurological:Patient denies numbness or weakness in legs.
Endocrine:Denies polydipsia or polyuria.
Hematologic:Denies bruising, bleeding, or infections.
Psychologic:Denies depression, anxiety or problems with sleep.
Objective Data: Vital Signs:BP –130/82 mmHg ; P – 80 beats/min, regular ; R – 12 breaths/min; T – 98.6 Fahrenheit; Wt. – 170 pounds; BMI – 24 kg/m2 Physical Assessment:
General: Well-appearing 45-year-old male in moderate distress. A&O x 3
Integumentary: No rash, unusual bruising, or prominent lesions
HEENT: Normocephalic; PERRLA; No thyromegaly, adenopathy or masses noted. Lungs: Bilaterally clear lungs to auscultation without wheezes, rales, or rhonchi. Heart: Regular heart rate and rhythm, no murmurs, rubs, or gallops. No edema. Abdomen: Soft, non-tender, without organomegaly or masses. Normoactive bowel sounds heard in four quadrants.
Extremities/Pulses: Warm and well-perfused, no cyanosis, clubbing, or edema.
Musculoskeletal:Normal curvature of the spine; Tenderness on palpation of left lumbar paraspinous muscle with increased tone; Normal gait, but moves slowly due to pain. Full range of motion with pain on flexion.
Neurologic:Straight leg raise (SLR) test is positive at 45 degrees on the left leg; Motor strength intact; Reflexes 2+ bilaterally at the knees, absent at the left ankle, 1+ at the right ankle Laboratory and Diagnostic Test Results:
MRI of spineafter progression of pain (Abnormal)
1. Moderate-size, herniated disc at L5-S1 with associated marked impingement on the left S1 nerve root and mild to moderate impingement on the right S1 nerve root. There is mild central canal stenosis.
2. Annular tear with a small central disc herniation at L4-5 causing mild central canal stenosis.
For acute low back pain, obtaining an MRI is not a part of the first line treatment. However, an MRI should be completed if the patient is having worsening or unremitting neurological deficit or radiculopathy, cauda equine compression, progressive major motor weakness, or the patient has failed six weeks of conservative care (Leong, n.d.). The MRI scan was ordered for Mr. Payne after he continued to have persistent back pain for over four weeks despite receiving physical therapy, an increase in his Naproxen to 500mg BID and a new prescription of acetaminophen with codeine at night. Laboratory tests; such as: CBC and sedimentation rates could have been ordered to rule out any infection or possible tumor (Leong, n.d.).
1. Low back pain, M54.5
2. Disc herniation, M51.27
3. Lumbar strain, S39.012A
MP’s occupation, clinical presentation, and MRI results all contribute to the reason he is having back pain. A herniated disk is when one of the rubbery cushions (disks) between a person’s bones (vertebrae) is pushed through a tear in the tougher exterior of the spine resulting in pain, numbness and weakness (Mayo Clinic Staff, 2018). A lumbar strain is described as an injury that causes pain in the lower back. The injury results in damaged tendons and muscles that can sometimes spasms without notice and make you feel sore (Johns Hopkins Medicine, 2019). Causes of a lumbar strain include: pulling and pulling sports (i.e. lifting weight and playing football). With disk herniation, the pain radiates down the leg and can sometimes causes numbness in the leg and foot drop (Leong, n.d.). With both lumbar strain and disk herniation, pain is worse with movement and sitting and is improved by being in the supine position (Leong, n.d.).
Plan of Care:
The conservative regimen for low back pain and disc herniation management is pharmacological therapy, local therapy and activity. Physical therapy will keep the patient active, decrease the patient’s back pain and overall reduce the amount of medications being used (Buttaro et al., 2017). Disc herniation’s explicitly responds better to extension-based exercise programs. Core strengthening can also promote lumbar stability by providing dynamic support (Buttaro et al., 2017). Alternative therapies that can be attempted include yoga, acupuncture, chiropractic manipulation, and massage therapy (Buttaro et al., 2017).
The first line medications for treatment of low back pain used for low back pain consist of nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants and acetaminophen. As discussed in the patient’s medical history, the patient was taking ibuprofen and naproxen for pain relief. The increase in dosage of naproxen for short-term pain management is appropriate. For patient education, it is important that the patient is aware that the use of NSAIDs are for short term use only due to gastrointestinal side effects (i.e. peptic ulcer disease) if taking on a consistent basis for a long period of time (Buttaro et al., 2017).
MP should be educated on mechanical low back pain and that most cases will resolve over time. The patient should also be encouraged to lose weight through proper exercise and diet. Additional education and pamphlets should be provided that shows proper body mechanics and the teach back method should be utilized. The patient should be referred to a spine specialist or an orthopedic spine surgeon if the pain is persistent, severe and functionally limiting or if the patient experiences progressive weakness or neurologic deficits (Buttaro et al., 2017). MP must be aware of emergency issues that necessitate immediate medical evaluation; such as, new limb weakness, or change in bowel or bladder function (Buttaro et al., 2017).
1. Discuss the Mr. Payne’s history that would be pertinent to his genitourinary problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
Mr. Payne is a 45-year-old man. Married with two daughters and drives trucks for a living. His job requires him to lift 30-45 pounds about four hours daily. Chief Complaint: He presents today with “severe low back pain that made it difficult to get out of bed this morning”. HPI: Complains of pain that is present for two weeks that radiates down left leg after lifting a 10-pound box. The pain is worse with sitting and improves with supine position, Ibuprofen, Naproxen and ice. No history of trauma, no fever/chills, no night pain, no urinary symptoms and no bowel or bladder incontinence. He reports a history of intermittent low back pain that is generally resolved in 2-3 days with NSAIDS. “He complains that this level of pain is the worst he has ever had it”. PMH: He has a hx of well controlled diabetes that he regards as fairly controlled, hypertension and hyperlipidemia. Social History: He quit smoking two years ago. Reports drinking 1 to 2 beers occasionally on the weekends. Denies any history of IV drug use. He denies any surgical history.
2. Describe the physical exam and diagnostic tools to be used for Mr. Payne. Are there any additional you would have liked to be included that were not?
Objective Data: Temperature: 98.6° Fahrenheit; Heart rate: 80 beats/minute; Respiratory rate: 12 breaths/minute; Blood pressure: 130/82 mmHg; Weight: 170 pounds; Body Mass Index: 24 kg/m2
A full examination of the back’s contours, curvature, functionality, including ROM and possible limitations should be performed while standing, sitting and lying down. should be performed. I would not order any other tests for this visit. Mr. Payne will be scheduled for a 4-6 week follow up to assess for status. Some of the diagnostic tests that are used in the assessment of Lumbar pain are: Complete blood count to assess for infection and inflammatory processes. An X ray due to the previous history of back trauma. Thirdly, an MRI to further assess for possible disc herniations.
1. Please list 3 differential diagnoses for Mr. Payne and explain why you chose them. What was your final diagnosis and how did you make the determination?
· Lumbar Strain- Pain is worse with movement and sitting
· Herniated Disc- Pain radiating down the leg and numbness
· Degenerative Arthritis- The pain is worse with movement and sitting
· Spinal Stenosis- Pain that improves with the supine position
4. What plan of care will Mr. Payne be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
· Based on Mr. Payne’s symptoms and exam his final diagnosis is Disc Herniation.Lumbar disk herniation is the protrusion, extrusion, or sequestration of the intervertebral disk from its usual anatomic location.
· It can result from normal aging or a recent trauma and cause mechanical compression of the nerve root by herniated material or sensitization of the nerve root.
Treatment of symptoms may include, Nonpharmacological interventions: Exercise may be effective in treating radicular low back pain. Physical Therapy can be instrumental in the strengthening, and decreased inflammation of lumbar spine (Asan, 2018).
Pharmacological interventions: Nonsteroidal anti- inflammatory drugs (NSAIDs) may be effective in treating radicular low back pain (Asan, 2018).
He would need to be educated on the condition, how to manage, monitor and prevent further exacerbation of his symptoms. The APRN will educate Mr. Payne on the importance of keeping a record or a journal of symptoms and reporting them to the MD. Mr. Payne will need to be made aware of “Red Flag” symptoms including, fever, chills, and reporting those right away. (Buttaro, Trybulski, Polgar-Bailey, Sandberg-Cook, (2017). As mentioned above Mr. Payne should be seen in 4-6 weeks to be assessed for medication, exercise and physical therapy outcomes.