NURS 6512 Week 8 Back Pain Essay
Case 1: Back Pain
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?NURS 6512 Week 8 Back Pain Essay
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
please ensure your SOAP Note contains enough hypothetical information to substantiate your assessment and plan. Lastly, for the sake of maximizing learning, I recommend providing a focused assessment. Your ROS and PE should always address the system for the week, and include general, cardiovascular, respiratory, and mental health.
For a focused note, you need to select systems based upon the chief complaint and HPI. Please review and revise. Additionally, please use consistent terminology – patient reports or patient denies.
Your justifications are good. However, you need to incorporate that level of detail in your HPI. Please revise accordingly. Consider it from this perspective – your HPI should tell a story of the chief complaint, and I should know your thought process regarding the differential diagnoses you are considering based upon what is documented
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
Chief Complaint: “Pain in my Lower Back and down my left leg”
HPI: Mr. John Pringle is a 42 y/o Caucasian male brick layer who reports LBP presenting approx. 1 month ago with no known trauma or obvious injury with worsening severity. States he has had some minor LBP through the years described more as an ache and noticed an occasional burning and tingling sensation which would radiate from his left buttocks down the left lateral leg to his foot for a couple of years now but states he ignored it as it only happened about once every 6 months and would resolve in a week or less without treatment describing it as more of an annoyance than pain. Today, he reports a near constant burning and tingling sensation accompanied by episodes of sharp, shooting pains following the same path as well as severe lower back pain rated 8-10/10 with certain movements. Currently at rest he describes a dull aching diffuse pain across his lower back. Pain is greatest when he bends to put his boots on before work in the mornings, doing leg lifts with his morning calisthenics and when he bends at the waist instead of using his knees to lift at work and reports when he tries to squat sometimes his legs feel shaky. The pain is consistent throughout the day ranging from 3/10-10/10 with certain positions and movements and by evening seems to worsen, especially on work days. He voices concern about permanent nerve damage as well as hurting his only co-worker if he would fall from a ladder or drop a load of bricks. He states OTC Motrin, Icy Hot and Epsom Salt baths as well as alternating ice packs and heating pads helps him relax enough to get to sleep at night. “But honestly, the pain is getting so severe that it is affecting my job, my home life with my wife and kids so much that I am getting scared and just need some answers”.NURS 6512 Week 8 Back Pain Essay
psycho-social/Social: Brick Layer, self-employed only he and his cousin work together. Married 20 years, 2 children, Recovered alcoholic – still attends Celebrate Recovery through his church- reports last drink 5 yrs. ago – quit after bleeding ulcer and marriage almost failed. States he was non-compliant with psych diagnosis and did not want to accept it. Denies illicit drug use, specifically IV. Denies prescription drug abuse. Current stress level increased with this back pain due to his line of work and wife recently miscarried at 20 weeks gestation. Older kids were excited about the new baby and states he and his wife had finally accepted it and were getting excited too. Past smoker 2ppd for 20 years- no other tobacco use. Quit smoking 2 years ago. States he has lost over 80 pounds in 2 years and has been exercising daily afraid to gain weight after he quit smoking and with his family hx of obesity. States he has reached his Wt. Loss goal and now wants to maintain. Was dealing with increased stress by working out more but now pain is interfering. States he asked for prayer at church on Sunday. Compliant with seat belts and safety glasses when cutting bricks at work. Family has private BCBS insurance, but price keeps increasing –May investigate a Christian Health share plan but states he is scared to do so while still having young children at home.
Mother: Living age 75, widowed and lives alone. L5, S1 Microdiscectomy at age 35, Paget’s Disease dx age 62 and Osteoarthritis, Bipolar and recent shingles.
MGM: deceased at age 80 Rheumatoid Arthritis dx age 30, morbidly obese.
MGF: Living 98 yrs. Lymphoma dx age 68
Father deceased at age 65: Massive MI, Mild Hemophilia dx age 3yr, Prostate Cancer dx age 63 Tx with seed implantation.
PGM: Living 95yrs: Fibromyalgia dx age 50 years Alzheimer’s dx age 80 lives in care home.
PGF: Deceased age 75 Alcoholism, Severe Scoliosis dx as young child uncertain of age but states he wore a back brace when initially dx. States he always walked with an uneven gait but could out work most anyone on the farm and was also a part-time brick layer
Brother: Living age 35 DM type I dx age 10 and Morbidly Obese
Sister: Living age 40: Hypothyroidism and Morbidly Obese
Son: Age 10 no concerns
Daughter: Age 7 no concerns
ROS
General: Reports desired wt. loss down 80 lbs. in 2 years with exercise and portion control low-fat low sodium diet. Reports difficulty getting to sleep due to the back pain but once asleep does not awaken until morning. Usually asleep by midnight and then up by 0630. Denies fevers, chills, fatigue, night sweats.
HEENT: Denies recent uveitis or iritis, eye pain, blurred or double vision, otitis media or sore throat
Cardiovascular: Denies chest pain, orthopnea, DOE, Peripheral edema or palpitations
Gastrointestinal: Denies Abdominal pain with or without meals, heartburn, blood in stools, nausea, vomiting or constipation, appetite changes or pain with a fatty meal, bloating, diarrhea or mucous stools. Denies scapular pain.
Respiratory: Reports morning cough with clear phlegm and mild seasonal allergies. Denies further cough, SOB, DOE, recent pneumonia, bronchitis or sinusitis, chest tightness or wheezing.
Genitourinary: Reports burning and hesitancy with urination. Denies incontinence, frequency, flank pain, malodorous urine, obvious hematuria or color change. Denies night time awakening for urination. Denies impotence of change in sexual frequency.
Musculoskeletal: Reports radiating pain L leg as per HPI, increased pain with forward flexion bending at waist, leg lifts and difficulty squatting at work to lift small pallets of bricks. Reports frequent leg cramps mostly left thigh occasionally left calf. Denies heel or foot injury, recent known trauma, recent fall, joint swelling, pain or tenderness, Denies obvious muscle weaknesses.NURS 6512 Week 8 Back Pain Essay
Neurological: Reports Numbness and tingling Left leg as per HPI. Denies Stumbling, obvious foot drop, change in balance or ataxia, shifting or leaning to one side or Headache.
Psychiatric- Reports irritability, difficulty concentrating and increased stress level due to chronic severe pain, work concern and recent loss of baby. Denies hx of anxiety attacks, past or current desire to harm himself or others and Denies desire to drink alcohol or start smoking again.
Endocrine: Denies polyuria, polydipsia, temperature intolerance or changes in hair or skin, excessive bruising, bleeding gums or noted petechiae.
Objective:
General – Mr. Pringle is a well-developed hard-working brick layer with noted concern expressed in his voice and by his words. Appears tired and mildly anxious shaking feet and wringing hands. Good eye contact, communication skills and a strong voice.
Skin: Intact, Pink warm and dry with good turgor. Note no lesions, rashes, lipomas or unusual hair patterns or patches over the spine. No jaundice or petechiae. No nail ridges, dents, lines or spots.
HEENT: Normocephalic, PERRLA, TMS intact with landmarks visible, no redness in canal or behind TM, no redness or drainage. Post oropharynx slightly pink with clear pnd noted. No lesions noted. Nares patent and pink. No sinus tenderness or pain.
Respiratory—Breath sounds are clear and equal bilaterally and percuss with normal resonance. Breathing non-labored with normal expansion and diaphragmatic excursion. Nail beds pink with refill less than 3 seconds.
Cardiovascular—RRR, tachycardia 110-115. No murmur, gallops, rubs, heaves or thrills. Normal S1, S2 no S3 or S4. Peripheral pulses plus 2 bilateral with no noted edema. No Abdominal bruit.
Gastrointestinal–The abdomen is flat soft, symmetrical without distention, non-tender – bowel
sounds normal and audible in all quadrants. No epigastric pain or tenderness. Kidneys palpable, smooth and non-tender. No masses, splenomegaly or hepatomegaly noted. No guarding or rebound.
Genitourinary: Slight tenderness reported with gentle palpation over symphysis pubis. Denies CVA tenderness or pain with fist percussion. No further exam pursued – however would consider if neuro symptoms were more acute.
Rectal: Deferred – would pursue if neuro symptoms were more acute do recommend Prostate exam and lab work for upcoming full physical due to family history of Prostate cancer.
Musculoskeletal: Gait posture upright and smooth with even strides. Strong muscular build. Normal spinal curvature with symmetrical alignment with scapula, iliac crests and gluteal crease. Legs equal length. No swelling, deformities, redness, warmth or pain noted to joints. Spine without point tenderness except at sciatic notch. Positive Lasegue’s at 45 degrees -Positive Bragard’s test also increased with internal rotation more pronounced with R leg lift. Pelvic tilt and other forward flexion increased pain and radiculopathy. Questionable Neg hip pain with FABER assessment — limited due to eliciting back pain. Neg hip click. Feet without deformities. Note high arches. Pain exacerbated with toe and heel walk as well as with squats. No muscle atrophy- calves and thighs equal size bilaterally. Positive Left hamstring tightness greater than right.
Neurological: No observed muscle twitching or tremors. Proprioception intact L great toe. Spinothalamis using sharp/dull with decreased sensation distinction from left lateral mid-calf across ant lateral L foot to 5th toe. DTRs intact and plus 2. Negative Babinski. Leg muscle strength plus 4 left plus 5 right. Decreased dorsiflexion and plantar flexion strength left foot. Decreased knee flexion and weaker left gluteus maximus in prone position. While sitting hip abduction weaker on left side. (Seidel, Ball, Dains, Flynn, Solomon, & Stewart, 2015).NURS 6512 Week 8 Back Pain Essay
Psychiatric: Positive demeanor although exam is painful for him. Cooperative. Smiles and interacts appropriately. Desires answers and states he hopes he hasn’t waited too long to seek help for the pain. Speech clear with avg speed, non-grandiose and appropriate. Direct eye contact. Bites nails and cuticles at fingertip no bleeding or sores noted.
Endocrine/Lymph: No tenderness or lymphadenopathy, Thyroid midline, non-enlarged and symmetrical bilaterally. Freely mobile and without palpable cysts or nodules.
Diagnostics:
MRI: Lumbar, Sacral region. – Because he has experienced the pain for over a month and the burning and tingling down his left leg for 3 years which is now worsening and presenting with some apparent neurological deficits, if insurance would allow the most definitive test suspicioning disc herniation would be an MRI (Dains, Baumann, & Scheibel, 2016).
Flat Lumbar Sacral Radiograph – indicated if insurance will not allow MRI as first line diagnostic. Due to his physically demanding and repetitious job of brick laying may reveal a fracture, tumor, degenerative changes or spurs as well as vertebral infection (Dains, Baumann, & Scheibel, 2016).
U/A with culture: Because he has a low-grade temperature and reported burning and hesitancy with urination, I would r/o a UTI and pyelonephritis.
Lab tests: With family history of Hemophilia, Paget’s disease, RA, Prostate CA, Fibromyalgia, DM, MI and Bipolar as well as his past personal history of alcoholism and Bipolar disease taking into account that he missed his last PE and lab work and it has been a full year since he had any lab testing – even if I was not his primary, I would draw these labs to help complete the picture and ensure that nothing infectious or systemic is taking place and not assume it is a herniation from PE findings only.
CBC & CMP: Low grade temp, possible UTI and C/O back pain undetermined cause and small amount of post nasal drainage. Assess electrolytes as well as additional LFTs with history of alcoholism and to rule out extreme possibility of early pancreatitis or gallbladder disease. Also monitor kidney function with Lithium.
ESR & ALP – ESR and ALP levels will be normal if back pain is from osteoarthritis or a mechanical cause and may be elevated with multiple myelomas, infectious spinal dx or ankylosing spondylitis while Alkaline phosphatase may be elevated with Paget’s disease. (Seller, & Symons, 2012).
PSA & Lithium level: PSA- Young age but with symptom of urinary hesitancy and family history of prostate cancer will be conservative and order. Lithium – Bipolar dx taking 5 years compliantly – need to check level for toxicity risk and to ensure it is at a therapeutic level
Uric Acid Level: Pt. History of Gout. Untreated, gout may result in a tophus formation or tophi which is the deposition of monosodium urate crystals surrounded by chronic mononuclear and giant-cell reactions which can be seen anywhere in the body including the spine (Sakamoto, Winalski, Rodrigues, Fernandes, Bortoletto, & Sundaram 2012). Patients with symptomatic spinal gout may present with a variety of symptoms, including back pain, radiculopathy, neurogenic claudication, cauda equina syndrome, paralysis, myelopathy, and fever with symptom duration ranging from one day to chronic and present with tophi deposits upon physical exam (Sakamoto, Winalski, Rodrigues, Fernandes, Bortoletto, & Sundaram 2012). Most will present with a history of polyarticular gout or an uncertain type of arthritis (Sakamoto, Winalski, Rodrigues, Fernandes, Bortoletto, & Sundaram 2012).
1. Herniated Disc with spinal compression at the L5, S1 level with radiculopathy.
Brick Layer, 3-year history of burning and pain possibly from a bulging disc with worsening symptoms and no injury or recent trauma. Dermatomal pattern of pain and burning radiating down buttocks, leg and foot as well as decreased sharp/dull sensation mid-calf down to toe. Decreased strength with dorsiflexion and plantarflexion as well as increased pain. Increased pain with SLR or Lasegue’s test, Bragard’s test, pronation, abduction of thighs and spinal flexion such as putting on his boots in the morning.
NURS 6512 Week 8 Back Pain Essay
2. Spinal Stenosis at L5, S1 Level with radiculopathy: More common in adults over 50 but with his physically demanding job he may have early degenerative changes (Dains, Baumann, & Scheibel, 2016). Due to the level of physical activity and various position he assumes as a brick layer, this dx may be difficult to differentiate. However, he does report more pain with Spinal Flexion versus hyperextension. The pain is reportedly worse at night on work days with increasing frequency of the radiating pain and burning; however, it is hard to ascertain the claudication type lower leg pain increases or decreases. Mr. Pringle reported a constant aching type pain to his lower back that only increased with certain positions and activities but was no longer returning to a 0/10 baseline or achieving full relief while sitting or resting. Without an MRI patient may need to journal or more closely assess these symptoms to help diagnose the source.
3. Bulging Disc L5, S1 with Sciatica — 3-year history of possible non-diagnosed bulging disc from symptomatology and fits dermatomal pattern. Repetitive, strenuous line of work. Reports chiropractic treatment every 6 months for H/A prevention but treatment may have delayed herniation and discs are still intact but bulging. Could consider more aggressive chiropractic care, Physical therapy and conservative treatment; however, with the neuro assessments on exam and changing pain status, I would want to see the MRI results before recommending such a route.
4. Osteomyelitis or Diskitis: Low grade fever, positive SLR test, no recent invasive testing such as a lumbar puncture of bone marrow aspiration, etc. No paravertebral muscle spasms or point tenderness except at the sciatic notch. Unlikely, however, caution is errored by drawing the lab tests.
5. Psychological Back Pain: Increased life stressors r/t miscarriage and this chronic pain. History of Bipolar and alcoholism; however, patient is now compliant with psych dx and treatment and remains pro-active with his alcoholism by attending weekly Celebrate Recovery meeting offered through his church. He enjoys his job and wants to be able to continue providing for his family. His wife is currently staying home, and he wants that to remain an option for her if she chooses. Unlikely diagnosis.NURS 6512 Week 8 Back Pain Essay