Case Study For Patient Complaining Of Lower Back Pain

Patient information

Patient initials:  J.F        Age: 62          Race: Caucasian        Gender: male

S.

CC:” Lower back pain”

HPI: J.F, a 62-year-old Caucasian man, presented to the clinic with the primary complaint of chronic lower back pain that began 8 weeks ago and has been radiating to the hip. The patient reported the pain as a dull throbbing ache, giving it a score of 7/10. He further reported the pain to increase with activity but lessened with rest. He further claimed that the ache becomes worse at night, disrupting his sleep. This prompted him to start using Tylenol 500mg OTC for pain relief, despite the fact that the improvement has been minimal. He also claimed to be fatigued. The patient indicated that his issues began a day after he was involved in a car accident wherein, he slammed his back severely on the curb, leaving him with bruises that have since disappeared but the ache has persisted. He claims he has no fever, nausea, vomiting, or diarrhea. Case Study For Patient Complaining Of Lower Back Pain

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Medication: Tylenol 500mg 2tab P0 PRN, and Synthroid 50mcg 1tab QD for managing pain, and hypothyroidism respectively.

Allergies: no known drug or food allergies

PMHX: Diabetes which were well managed by lifestyle modification and hypothyroidism managed by mediation.

Immunization: up to date. Last received his MMR 7/3/2022, and HEP B vaccine 6/1/2022

Past surgical history: none reported.

Family history: Father (85-y/o): hypothyroidism. Mother (81 y/o): Breast cancer. Maternal grandfather (deceased): diabetes. Maternal grandmother (deceased): hypertension. Maternal grandfather (deceased): COPD.

Social history: J.F, a 62-year-old Caucasian patient, works as a professor at a nearby technical university full-time. He is married to a single woman and has two children, ages 23 and 28 years old. Denies smoking but concedes to occasionally drinking alcohol. He doesn’t have time to exercise since he spends so much time gardening. He is financially solvent, and his family’s health is covered by insurance. He claimed that he lived in a safe neighbourhood, that he always wears his seat belt, and that he never uses his phone while driving. Eats a well-balanced diet rich in fruits and vegetables. Case Study For Patient Complaining Of Lower Back Pain

ROS

General: Denies fevers, chills, or significant changes in weight.

HEENT: Denies loss of vision, and hearing, nosebleed, sinusitis, and post nasal drip.

Cardiovascular: Denies chest pain, irregular heartbeats, heart murmur, and pain in the feet.

Respiratory: Denies SOB, night sweat and chronic cough

GI: Denies decrease in appetite, heartburn, frequent belching nausea, vomiting, or diarrhea.

GU: Denies pain, or burning with urination, urinary urgency and frequency.

Msk: Reported chronic back pain that radiates to the hip.

Neurologic: Reported unexplained headache, and dizziness, denies muscle spasm, and fainting.

Psychiatric: Denies depression or anxiety. Denies homicidal ideation.

Endocrine: Denies heat or cold intolerances.

Skin/lymph/heme: Denies skin redness, rash, or changes in skin colour. Case Study For Patient Complaining Of Lower Back Pain

O.

PE

VTS: BP 128/66 left arm, sitting using regular adult cuff. Wt.: 201lb Ht.: 5’7 T.: 37.4 RR: 20 P: 80 Sp02: 98%

General: A&Ox3, no acute distress except for his chronic pain in his lower back. Well-nourished. Appear his stated age.

HEENT; normocephalic and atraumatic. Visual acuity 20/20. EOMI, PERRLA. Snares patent bilaterally. Hearing intact with good acuity. Carotid pulse 2+ bilaterally without bruit.

Cardiovascular: RRR, no murmur, gallops or rubs, SI and S2 heard and are of normal intensity.

Respiratory: Chest wall is symmetric and non-tender. Lung sound clear without rales. No signs of respiratory distress noted. Resonance is normal upon percussion.

MSK: Full range of motion noted in all joints. Pulses palpable. Lower back pain noted with flexion.

Skin: Warm and dry. Intact without rashes. Normal texture. appropriate color for ethnicity.

Abdomen: Soft and symmetrical without distention. Bowel sounds are normoactive. No masses noted.

Extremities: Atraumatic without tenderness.  Muscle strength 5/5 bilaterally.

Neuro:  Sensation intact bilaterally.  Memory and thought process intact.

Psychiatric: Oriented to place and time, no abnormal affect noted.

Assessment: Case Study For Patient Complaining Of Lower Back Pain

Chronic lower back pain

Lab test and result

Lasegue test to asses lumbosacral nerve root irritation: positive

CBC to point out infection or inflammation: result pending

Erythrocyte sedimentation rate: result pending

Diagnosis

Sciatica

Sciatica is a medical disorder that causes pain to radiate from the lower back down the hip, buttocks, and leg. The sciatic nerve, the body’s biggest nerve, is squeezed, causing this pain.  Obesity and persistent back pain are two more causes of sciatica. High-impact activities such as hamstring stretches and sleeping might increase sciatica pain (Jensen et al.,2019). Based on the patient’s history of chronic pain after an accident, diabetes background, and lab results, it is the most likely diagnosis.

Herniated disc

A herniated disc is an issue with one of the rubbery cushions (disks) that sit between the spine’s bones. It can occur as a result of spine injury that puts strain on these disks. This can cause back pain, loss of flexibility, and other issues. While a variety of factors might lead to a herniated disk, the most frequent cause is a vehicle accident or a fall (Cunha et al.,2018)Case Study For Patient Complaining Of Lower Back Pain. This disease is differentiated by the position of the herniated disc. If it develops in the lower back, it causes discomfort to radiate to the hip and leg. It also produces numbness in the leg or foot, as well as reduced flexion, which were not observed in the case situation.

Osteoarthritis

Osteoarthritis is a kind of arthritis caused by the breakdown of cartilage in the joints. With time, the cartilage degrades and the bones scrape against one other, exerting additional pressure on the nerves, particularly those leading to the lower back and hips, resulting in pain, edema, and stiffness (Sharma,2021). Osteoarthritis can affect any joint, including the knees. This illness is distinguished by a low-grade temperature and loss of appetite, both of which were absent in the case scenario.

Primary diagnoses: sciatica

P.

Lab test:  X-Ray on lower back and hips is necessary

Medication: start the client on Lortab 5/325 PO Q6H PRN and recommend OTC, Aleve to be used for pain.

Non-pharmacological: Ice Therapy for 30 minutes Q6H as needed

Patient education: The patient must be taught when is necessary to the prescription because Lortab, an opioid-based medication can be addictive if misused or abused. The client must be instructed about how to utilize ice therapy and the precautions that must be taken throughout the operation. Because persistent low back pain is linked to lifestyle factors, the client must be educated on the need of altering certain lifestyle behaviours’, such as quitting smoking, for better results.

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Follow-up: The client should visit the clinic after 2 weeks for further check-up

Referral: To physical therapy for further guidance

References

Jensen, R. K., Kongsted, A., Kjaer, P., & Koes, B. (2019). Diagnosis and treatment of sciatica. Bmj, 367.

Cunha, C., Silva, A. J., Pereira, P., Vaz, R., Gonçalves, R. M., & Barbosa, M. A. (2018). The inflammatory response in the regression of lumbar disc herniation. Arthritis research & therapy, 20(1), 1-9.

Sharma, L. (2021). Osteoarthritis of the knee. New England Journal of Medicine, 384(1), 51-59 Case Study For Patient Complaining Of Lower Back Pain