Subjective Data
Chief Complaint (CC): lower back pain.
History of Present Illness (HPI)
A 64-year-old Hispanic male presents to the office with complaints of lower back pain. The pain started suddenly a few days ago; it is dull, and it is accompanied by feelings of tightness. Associated symptoms are stiffness in the lower back and limited range of motion. The pain worsens with movement, and Advil taken recently did not relieve pain for a long period of time. The patient notes that resting helps to a degree, but as he gets up or sits for too long, the pain starts again. He rates the severity of pain at 6/10 and says that it never happened before.
Medications
- Lipitor 10mg daily – for lowering high cholesterol
- Norvasc 5mg daily – for antihypertensive therapy
- Diovan 60 mg daily – for antihypertensive therapy
- Multivitamin one tab daily – for general health
Allergies
NKA.
Past Medical History (PMH)
The patient has a history of high cholesterol and diabetes mellitus. He takes medications and has both conditions under control. HR also uses medications for antihypertensive therapy to prevent cardiovascular problems. HR did not have any issues with severe back pain in the past.
Past Surgical History (PSH): No history of major surgeries.
Sexual/Reproductive History
The patient is heterosexual, has had one long-time partner for years, uses protection.
Personal/Social History
The patient does not smoke cigarettes or use drugs, but he drinks alcohol recreationally once a week or less. He is married and has two adult children who live separately. His work is not strenuous, but he enjoys doing yard work which often requires physical activity such as lifting.
Immunization History
His immunizations are up to date – Influenza November 2018, Td booster three years ago.
Significant Family History
The patient has two younger sisters. The first one is 59 years old; she was recently diagnosed with diabetes type 2. The second sister is 57; she has hypertension which is well-controlled. HR has two children – a daughter 40 years old, generally healthy, and a son 35 years old, healthy. HR also has three grandchildren – 17, 13, and 10 years old.
Lifestyle
The patient has recently retired from his full-time job, but he still accepts some work inquiries as he is an electrician. He has a wife of 36 years; she is 60 years old, and they live together. HR’s children visit them often, and they spend some time with grandchildren as well. He prefers to work to ensure financial stability and keep busy. He likes to do yard work and look after the house, but he also spends much time inside, watching TV.
Review of Systems
General: No fever, chills, sweats, recent weight change, or fatigue.
HEENT: Head: no recent injury or trauma, no hair loss. Eyes: no changes in vision, HR wear reading glasses and has hyperopia, diagnosed around three years ago. No blurred or doubled vision, no yellow sclerae. Ears: no hearing loss, ear infections, or discharge. Nose: no rhinitis, changes in the sense of smell, or sinus infection. No sneezing or congestion. Throat: no sore throat, difficulty chewing or swallowing.
Neck: No pain in the neck, no stiffness or injury. The patient has no history of neck pain, disk suppression, or degradation.
Respiratory: No pain, cough, no history of allergy, asthma, emphysema, or lung injury.
Cardiovascular: No chest pain, discomfort, murmurs, palpitations, irregular heartbeat. The patient states that he has hypertension, but medications make the BP normal.
Gastrointestinal: She uses fiber as a daily laxative to prevent constipation. No nausea, vomiting, abdominal pain. No bloating, constipation, or diarrhea.
Genitourinary: No changes in frequency, urgency, or hesitancy. No nocturia, incontinence, or pain during urination. No history of STIs. The patient is sexually active with his wife, uses protection (male condoms).
Musculoskeletal: No history of fractures or trauma. The patient’s range of motion is limited. He has not been diagnosed with arthritis or gout.
Psychiatric: No history of anxiety, nervousness, depression, mood changes, insomnia, memory loss, or auditory/ visual hallucinations. No suicidal or homicidal desires, no recent loss in the family or friends.
Neurological: The patient has no history of stroke, seizures, tremors. No headache, dizziness, paresthesia. No numbness in the lower extremities.
Integument/Heme/Lymph: No itching, bruising, bleeding, or rashes. No history of skin cancer. No heat or cold intolerance, no history of blood transfusions.
Endocrine: Diabetes mellitus diagnosed in 2015. The patient had no recent history of complications or hypoglycemic episodes.
Allergic/Immunologic: The patient has no known food, animal, drug allergies.
Objective Data
Physical Exam
Vital signs: BP 128/80, P 72 regular, T 97,9 F, RR 14 non-labored, SpO2 92%.
Height: 5’8” Weight: 163 lbs, BMI 24.8.
General: A&O x3, answers questions clearly. Uncomfortable due to limited movement and pain.
HEENT: Head: normocephalic, no bumps, lesions, or bruises. Eyes: PERRLA, hyperopia, vision 20/20 both eyes, no hemorrhages or exudate. Sclera white, conjunctiva pink. Ears: acuity high, no redness or inflammation. Nose: mucosa pink, no tenderness, flaring, or discharge. Throat/Mouth: no redness, membranes moist and pink.
Neck: No lymphadenopathy, no enlargement, or tenderness.
Lungs: No wheezing, crackles, or rhonchi; breathing is vesicular.
Heart/Peripheral Vascular: No murmurs, gallops, rubs. S1 and S2 regular, no S3 or S4. No chest pain to palpation pulses +2 bilaterally.
Abdomen: Protuberant, soft, non-tender, normoactive bowel sounds in all four quadrants, no pain upon palpation, no masses.
Genital/Rectal: Deferred as requested by the patient.
Musculoskeletal: No edema in extremities, normal gait. Range of motion on extension, bending, rotation (left and right), and flexion with tenderness. In joints – a full range of motion, no deformity. In the lumbar area – palpable tension, possible muscle spasm. No loss of sensation, positive monofilament test in both feet.
Neurological: Cranial nerves are intact.
Skin: Soft, warm, dry to touch. No rashes, bruises visible.
Lymph Nodes: All nodes (head, neck, axilla, epitrochlear, inguinal) are nonpalpable.
Assessment
Lab Tests and Results: No lab tests were performed.
Diagnostics
- Monofilament test positive to both feet.
- Straight leg raise test negative.
Primary Diagnosis
Lumbar sprain (mechanical low back pain, or LBP). One of the most common mechanical issues, a sprain, is an injury of muscles and ligaments that are caused by overexertion and stress of a joint (Allegri et al., 2016). In this case, the patient’s yard work may have resulted in this injury. Mechanical LBP is characterized by a sudden onset, a limited range of movement, stiffness, and increased pain during physical activity (Naser & AlDahdooh, 2016).
Differential Diagnosis (DDx)
- Herniated disk. It is an injury to the tissue that is located between vertebrae (Buttaro, Trybulski, Polgar Bailey, & Sandberg-Cook, 2017). It may be caused by overexertion and is defined by LBP, pain in extremities (legs), numbness, tingling, and weakness (Allegri et al., 2016). The negative straight leg raise test and the lack of numbness in the lower extremities weaken this diagnosis.
- Degenerative disk disease. A condition where intervertebral disks lose their normal functioning (Samartzis et al., 2015). This results in LBP, which can radiate to hips, buttocks, and legs (Buttaro et al., 2017). The patient does not have a tingling sensation, and his pain is topical.
- Osteoarthritis. Damage to bones’ protective cartilage that leads to joint pain, tenderness, stiffness, and loss of flexibility. To exclude the diagnosis, an X-ray test should be performed. However, if the pain subsides in time, it is not necessary (Buckland, Miyamoto, Patel, Slover, & Razi, 2017). HR does not have any swelling or redness in the affected area.
Diagnoses/Other Client Problems
- High cholesterol
- Diabetes type 2
- Hypertension
Plan
The patient needs to follow a RICE approach – rest, ice (or heat), compression, elevation. Any strenuous activity has to be avoided, but the patient should participate in his usual tasks to improve the range of movement. If the symptoms worsen, additional tests will include a CT scan or MRI and CBC to exclude infection and other causes. Ibuprofen 300 mg as needed (no more than four times a day) is prescribed for pain relief (“Ibuprofen dosage,” 2018). Patient education includes exercises to lower stress on back muscles.
Reflection
This patient’s case allowed me to learn more about musculoskeletal problems. It is clear that such issues as lower back pain are common, but they present a challenge to practitioners because they may relate to many causes. The patient’s age, other diagnoses, and social history played a significant role in choosing a diagnosis. Moreover, his description of pain was also vital in distinguishing between various conditions. I agree with the preceptor’s course of action and treatment plan since many LBP complaints are related to mechanical problems. If this patient’s pain is related to another disorder, his acute condition may not reveal the true cause instantly. The patient leads a healthy lifestyle and seems to comply with health providers’ directions, so I would not change this plan of action. Overall, this experience showed me that many disorders have similar presentation and minute details, as well as a patient’s collaboration may determine the health professionals’ conclusions.
References
Allegri, M., Montella, S., Salici, F., Valente, A., Marchesini, M., Compagnone, C.,… Fanelli, G. (2016). Mechanisms of low back pain: A guide for diagnosis and therapy. F1000Research, 5(1530), 1-11. Web.
Buckland, A. J., Miyamoto, R., Patel, R. D., Slover, J., & Razi, A. E. (2017). Differentiating hip pathology from lumbar spine pathology: Key points of evaluation and management. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 25(2), e23-e34.
Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier.
Ibuprofen dosage. (2018). Web.
Naser, S. S. A., & AlDahdooh, R. M. (2016). Lower back pain expert system diagnosis and treatment. Journal of Multidisciplinary Engineering Science Studies (JMESS), 2(4), 441-446.
Samartzis, D., Borthakur, A., Belfer, I., Bow, C., Lotz, J. C., Wang, H. Q.,… Karppinen, J. (2015). Novel diagnostic and prognostic methods for disc degeneration and low back pain. The Spine Journal, 15(9), 1919-1932.