Back pain | Nursing homework help

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Initials: J.S    Age: 42     Sex: Male   Race: African American 

S.

CC:  “I am experiencing lower back pain that radiates to my left leg”

HPI:  Mr. Smith is a 42-year-old African American male who reports to the clinic complaining of lower back pain that periodically radiates to his left leg.  The pain started about one month ago.  The character of the pain is shooting and stabbing. It appears to get worse when sitting for an extended period of time, bending over and during strenuous physical activity. The severity of the pain is 8/10 without medications but relieves to about 3/10 after taking Tylenol and getting some rest.  

Location: Lower back

Onset: 1 month

Character: Shooting and Stabbing

Associated signs and symptoms: nausea, vomiting, photophobia.

Timing: Sitting for extended periods, bending over and strenuous physical activity. 

Exacerbating/ relieving factors: Tylenol and rest makes the pain tolerable, but not completely better.

Severity: 8/10 pain scale

Current Medications: 

Metoprolol 100 mg tablet, PO once daily. 

Acetaminophen 500 mg tabs, 1-2 PO q 6 hrs, PRN for pain. (not to exceed 3 g in 24 hr).

PMHx:

Diagnosis: Hypertension

Surgical Hx: Laparotomy, 02/2000

Immunizations: Childhood immunizations completed. Tetanus and Flu shots are up-to-date.

Soc Hx: Unemployed. Lives alone and never married. Has one brother and both parents are alive. Performs physical exercise regularly at the gym, and uses seat belts all the time when driving. Denies tobacco and alcohol use.

Fam Hx: Father has a stroke and heart disease, Mother has hypertension, Brother has diabetes. Maternal and Paternal grandparents died of a stroke 2 years ago.

ROS:  BP – 140/90 L arm,  P – 86, T – 98.1 oral,  RR – 18,  Ht. – 5’10”, Wt. – 200 lbs. BMI 28.7

GENERAL:   No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, doubles vision or yellow sclerae. 

Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

Skin: No rash or itching. No skin lesions or moles that are new or suspicious.  

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema. No pleurisy pain, no hx of a heart murmur. No EKG on record. No peripheral edema or claudication. BP controlled with medication. 

RESPIRATORY:  No cough, sputum or SOB. No DOE, hemoptysis. Chest X-rays – 3 years ago. 

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. No unintentional weight loss or gain. No change in bowel habits.

GENITOURINARY:  No penile discharge or erectile dysfunction. No nocturia, dribbling, or incontinence.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. No reports of numbness or tingling to the left leg since the onset of lower back pain.

MUSCULOSKELETAL: Reports lower back pain that sometimes radiate to the left leg. No edema noted. 

HEMATOLOGIC:  No hx of Blood transfusions. No anemia, bleeding or bruising. 

LYMPHATICS:  No hx of splenectomy. No enlarged lymph nodes.

PSYCHIATRIC:  No hx of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. No heat or cold intolerance.

ALLERGIES:  NKFA, NKDA

O.

Physical exam: 

General: Alert & Oriented x3. Appears well-nourished but exhibits a slight limp due to left leg pain.

Cardiovascular: Regular heart rate and rhythm, normal heart sounds and intact pulses. No murmurs, gallops or pericardial friction rub.

Pulm/chest: No respiratory distress. Lung Sounds clear to auscultation in all fields.

Abdomen: Soft, non-tender, Bowel sounds present x4 quadrants.

Musculoskeletal: Decreased mobility with lower back pain. Limited ROM with lumbar flexion. Gait disturbances, leaning to the right side on examination. Muscle spasms noted.

Hip flexion/ extension and strength against resistance indicates weakness to left gluteus maximus and L5 nerve root involvement. No hip or joint instability, knees equal in height

Neurological:  Bilateral L3-S1 dermatomes reactive to touch, no decrease in sensation. Deep tendon reflexes are symmetrical.  Knee jerk reflex positive and symmetrical bilaterally. 

Diagnostic results: 

Urinalysis: Negative, Light-yellow urine.

A.

Differential Diagnoses: 

1. Low back pain & sciatica – Shooting pain in the lower back, that radiates down to one leg.
2. Degenerative disc – The gradual deterioration of the disc between the vertebrae. 
3. Lumbar radiculopathy – Nerve irritation caused by damage to the discs b/w the vertebrae. 
4. Herniated disk -Signs and symptoms include arm/leg pain, numbness/tingling, and weakness. 

The presenting low back pain symptoms indicate a sciatic nerve involvement since the pain is radiating down the posterior aspect of the left leg. The X-rays show lesions most likely at the L-5. Further tests that may be ordered include; Schober test. This test measures the ability of a patient to flex his lower back. The patient is asked to touch his toes while keeping the knees straight. A positive test will be less than 4 cm between the 2 marks indicating decreased lumbar mobility. A Straight Leg Raise (SLR) test can be used to determine if the patient has true sciatica. A positive SLR test usually indicates S1 or L5 root irritation.

A FABER test can be used to rule out Sacroiliac (SI) Joint Pain and sacroiliitis. It is considered positive if movements reproduce pain or cannot be completed due to limited range-of-motion. Nerve testing of the lower extremities can be used to detect nerve irritation, while disc herniation can be detected with radiology testing, such as CT scan or MRI scan (McCance et al., 2014).

According to El Barzouhi et al., (2013), patients with sciatica frequently experience disabling back pain. Sciatica or lumbar spine pain with nerve root involvement results in low back pain and leg pain. The condition generally resolves within a period of 8 weeks. If the low back pain does not resolve within 8 weeks, then consider using imaging techniques such as; CT scan or MRI (El Barzouhi et al., 2014).                         

Diagnostic testing is not usually recommended within the first four weeks of the onset of low back pain, with no neurological symptoms, according to national practice guidelines (Dains, Baumann, & Scheibel, 2012). Evidence shows that unnecessary or routine imaging (X-ray, MRI, CT scans) for low back pain is not associated with improved outcomes. Patients who have early imaging had much greater health care use and costs, but they did not have better outcomes (AHRQ, 2015). 

References

Agency for Healthcare Research and Quality (2015). Back pain? Hold the MRI, new research says. Retrieved from https://www.ahrq.gov/news/newsletter/e-newsletter/464.html

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. (2012). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St.Louis, Missouri: Elsevier.

El Barzouhi, A., Vleggeert-Lankamp, C. L. A. M., van der Kallen, B. F., Lycklama à Nijeholt, G. J., van den Hout, W. B., Koes, B. W., & Peul, W. C. (2014). Back pain’s association with vertebral end-plate signal changes in sciatica. The Spine Journal, 14(2), 225–233. https://doi-org.ezp.waldenulibrary.org/10.1016/j.spinee.2013.08.058

McCance , K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2014). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MS: Elsevier.