HPI: A 42-year-old Latino male presents to the office with complaints of lower back pain. It has been persistent for a month; the pain is mild, but it sometimes radiates to his left leg. It does not subside without medication and is stronger after sitting for a long time or physical activity. The patient rates his pain as 5/10 at most times.
Current Medications: Ibuprofen 400 mg occasionally, not more than 2 tablets per day.
Allergies: NKDA.
PMHx: Td 2016.
Soc Hx: AL works as a risk manager at an architectural company. His work is not-active; he works out sometimes. Additional information about recent traumas and physical activity is vital for the diagnosis (Maher, Underwood, & Buchbinder, 2017). He has a spouse and 2 children, daughter (18) and son (15). He drinks alcohol recreationally, denies tobacco or drug use. AL admits to not thinking about his posture when he sits or walks.
Fam Hx: Mother died from cardiovascular complications at 73; she had hypertension. Father died in a car crash at 45.
ROS
- GENERAL: Weight is stable, no chills, fever, or fatigue.
- HEENT: Eyes: No changes in vision, sclera are white, no blurred or impaired vision. Ears, Nose, Throat: No hearing problems, sneezing, or sore throat.
- SKIN: No itching or rashes.
- CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. No chest pain, no discomfort, pressure, edema, or palpitations.
- RESPIRATORY: No dyspnea, cough, or sputum.
- GASTROINTESTINAL: No nausea, vomiting, abdominal pain constipation, or diarrhea.
- GENITOURINARY: No changes in frequency or consistency.
- NEUROLOGICAL: Additional information should be collected about numbness, tingling, cramping, weakness, or pain in legs and feet.
- MUSCULOSKELETAL: Lower back pain, sometimes followed by left leg pain. More questions should be asked about lower back stiffness, restricted motion, muscle spasms, saddle anesthesia (Eisenberg, 2016).
Physical exam
GENERAL: The patient appears well-nourished, oriented, and alert, answers clearly and quickly.
H: 5’9”
W: 177 lbs
BP 123/78
P 76
- SKIN: Soft, warm, dry to touch, no erythema or color changes.
- CARDIOVASCULAR: RRR, no clicks, no murmurs. Good S1 and S2, no S3 or S4.
- ABDOMEN: Protuberant, normoactive bowel sounds in all 4 quadrants; no pain upon palpation.
- RESPIRATORY: Lungs clear to auscultation, no cough, wheezes, or restricted breathing.
- NEUROLOGICAL: Normal gait, maintains balance without issues with eyes closed. Deep tendon reflexes exam shows decreased patella reflex; Achilles reflex normal.
- MUSCULOSKELETAL: Physical exams include Range of Motion (ROM). Lumbar flexion 90 degrees with pain, lumbar extension 15 degrees, lateral motion 45 degrees (Sullivan, 2019).
Diagnostic results: Physical tests are vital for finding the cause of pain. Mentioned above exams target L3-L4 and L5-S1 level nerves to exclude or support nerve impingement (Ball, Dains, Flynn, Solomon, & Stewart, 2015). An x-ray can show scoliosis, broken bones, infection, or tumor. MRI can be performed if tumors are suspected or if the location of damage cannot be found through physical exams.
Differential Diagnoses
- Mechanical low back pain. The patient’s posture or recent physical activities can cause pain (Maher et al., 2017). Normal results of a physical exam indicate the absence of other problems. Diagnostics such as a monofilament test are needed to confirm protective sensation in feet.
- Herniated disk. The pain during lumbar flexion exam indicates possible herniation. Decreased patella reflex suggests L3-L4 nerve impingement as well, which is characterized by pain radiating to one or both legs (Ball et al., 2015; Maher et al., 2017). MRI can be performed to prove the diagnosis.
- Spinal stenosis. Lumbar spinal stenosis is characterized by lower back pain, numbness or tingling in legs, and pain after standing or walking. An x-ray can show a narrowing in the spinal canal (Maher et al., 2017). Pain during lumbar extension would support this diagnosis. A stoop test can also be performed.
- Osteoarthritis. Pain during flexion may suggest osteoarthritis. Pain during bending should be assessed; symptoms include pain, loss of flexibility, joint stiffness, and bone spurs (Ball et al., 2015).
- Radicular pain. Radiculopathy can be suggested if the patient experiences pain in an “L4, L5, or S1 nerve root distribution,” (Maher et al., 2017, p. 738). Straight leg raise and crossed straight leg raise tests can confirm this condition.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
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.
Eisenberg, J. M. (2016). Noninvasive treatments for low back pain: Current state of the evidence. Web.
Maher, C., Underwood, M., & Buchbinder, R. (2017). Non-specific low back pain. The Lancet, 389(10070), 736-747.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.