a 42 year old male reports pain in his lower back for the past month the pain sometimes
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Wk#8 Case#1
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?
Patient Information:
M.S. Age 42 Caucasian Male
S.
CC: “Lower Back Pain”
HPI: The patient is a 42-year-old white male who developed lower back pain for 1 month. He
states the pain radiates to his left leg. His lower back pain is increased with sitting for long
periods of time, states the pain gets better when stands. Denies any fever, chills, and sweating.
Current Medications: Omeprazole 20 mg daily, Atorvastatin 40 mg daily, Motrin 200 mg two
every 4 to 6 hours as needed for pain
Allergies: No known drug, food, or environmental allergies.
PMHx: GERD, Hypercholesterolemia
PSHx: Adenoidectomy 1975
Soc Hx: M.S. is a retired plumber who lives alone. He enjoys activity such as walking, bike
riding and camping outdoors.
Personal/Social History: Patient denies ever smoking cigarette. Denies any recreational drug
use.
Fam Hx: Mother alive, age 72-years-old, breast cancer at age 52 in remission. Father died at age
70 (2yrs ago) – history of CAD, MI age 70 died.
ROS:
GENERAL: No weight loss. Complaint of lower back pain. No complaint of fever, chills,
weakness, fatigue, constipation, bladder or bowel incontinent.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose,
Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching.
This study source was downloaded by 100000839832718 from CourseHero.com on 04-25-2022 18:03:54 GMT -05:00
, CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or
edema.
RESPIRATORY: No Complaint of sob, no cough.
GASTROINTESTINAL: patient reports occasional heartburn. No anorexia, nausea, vomiting or
diarrhea. No abdominal pain or bowel incontinent, no rectal pain or bleeding
GENITOURINARY: No difficulty with urination, no urinary leakage or incontinence.
NEUROLOGICAL: No headache, no dizziness, no syncope, no paralysis, no ataxia, no
numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: complaints of lower back pain radiates to back of right leg. Pain 8/10,
sometimes increase pain when turning in bed, walks with limp when having pain. Patient reports
a lower back for one-month, intermittent pain when ambulating that shoots down the right,
lateral thigh, down to the knee, and no numbness of leg. The patient states his pain is relieved
somewhat with his OTC Tylenol. Patient denies any swelling, redness or heat at any of the joint
sites.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes in the groin. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No complaints of fever, chills, and sweating.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
Physical exam:
VS: BP 159/82; P 72; R 18; T 98.7F; O2 SAT 98%; Wt. 210 lbs.; Ht 5’8”, pain 8/10 on scale of
0-10 at rest
General: 42-yr-old Patient presents as a well-developed, young adult Caucasian who appears his
stated age. He is alert, oriented, and cooperative. The patient walks with slight limp,
HEENT: normocephalic head with normal distribution of hair. No facial tenderness to light
sensation. Conjunctiva are pink with white sclera and without jaundice. PERLA, with pupils
3mm in size bilaterally. No exudates seen. Nasopharynx and pharynx without erythema, lesions,
or exudates. Mucous membranes are moist. Upper and lower teeth in good condition and intact.
The trachea is midline.
Neck: normal ROM, Supple with no JVD or bruits, there is no adenopathy. No swelling noted.
Chest/Lungs: Lungs are clear to auscultation anteriorly and posteriorly with equal symmetry of
chest rise and fall. Resonance noted to percussion bilaterally. No wheezes, rhonchi or stridor.
This study source was downloaded by 100000839832718 from CourseHero.com on 04-25-2022 18:03:54 GMT -05:00
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