EST/AR (ignore this. It’s to help remember which post I chose)
Choose a classmate who was assigned a different case study than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning. (Doesn’t need to be super in depth. 2 paragraphs and 2-3 source will be fine)
Post:
Patient Initials: C. N. Age:42 Sex: Male Race: African American
CC: Lower back pain
HPI: C N. is a 42-year-old male who presents today with a lower back pain. He reports he has been having this lower back pain for the past month. He reports the pain sometimes radiates to his left leg and rates the pain level 7 out of 10 on a scale of 1-10. He takes Ibuprofen as needed to relieve the pain.
Current Medications: Ibuprofen 200mg 2 tablets every 4-6 hours as needed for lower back pain.
Allergies: No known allergies
PMHx: Denies any past medical histories. Up to date with immunizations, last tetanus shot 06/13/19.
Soc Hx: He is a registered nurse in one of the local hospitals, single, never been married, and has no children. Hobbies are reading, swimming, and traveling. Denies any tobacco use but states he drinks alcohol occasionally. Reports the use of seat belt always when handling a moto vehicle and denies texting when driving.
Fam Hx: Father died due to old age at the age of 65, mother died due to moto vehicle accident at the age of 50. Unaware of both paternal and maternal grandparents’ medical histories. No siblings as he is the only child of his parents.
ROS:
GENERAL: Appropriately dressed for the weather, no weight loss, fever, chills, weakness or fatigue.
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, lesions or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No difficulty breathing, cough , or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or bleeding.
GENITOURINARY: No burning, retention, or urgency on urination.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in all extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Lower back pain for the past month, pain sometimes radiates to the left leg.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
Vital signs: BP 125/78 Left arm; P 74; T 97.6 orally; R 19 and unlabored; SpO2 100% right arm; Weight 182 lbs; Height 6’3”.
Physical exam:
GENERAL: Patient is alert and oriented to person, place, date, and time, well dressed and pleasant. Speech cleat and coherent.
HEENT: Head is symmetrical, pupil equal round and reactive to light and accommodation, ears well-formed and positioned with no hearing loss, lesions, or drainage noted; nose intact with no deviated septum, throat is clear, pink and moist with no swellings noted.
NECK: No jugular vein distention noted, carotids noted with no bruits.
SKIN: Skin color appropriate for race, intact, no rashes, erythema, or lesions noted.
CHEST/LUNGS: Chest rises and falls symmetrically; lung sounds clear to auscultation.
HEART: Regular rate and rhythm noted, no palpitations or murmurs noted, capillary refills less than 3 seconds on all extremities, equal palpable pulses, no cyanosis or clubbing noted.
MUSCULOSKELETAL: Muscles are developed symmetrically, no swelling noted to lower back or left leg, patient verbalized pain gets worst with bending, walking, and standing for long, tenderness and spasm noted on palpation, limited range of motion upon forward flexion of spine, no neurological abnormalities noted.
Diagnostic results:
A complete medical history and physical exam can usually, identify any serious conditions that may be causing pain. Even though the cause of lower back pain is difficult to determine even after a thorough examination. Here are some test used in the diagnoses of lower back pain such as:
Blood test- blood test are not used to diagnose the cause of back pain but might be ordered to look for signs f inflammation, infection, cancer and arthritis.
Straight Leg Raising: To test for sciatic L5 and S1 nerve root tension (Dains et al., 2019).
Spinal radiograph: To rule out fractures, osteophytes, tumors, or vertebral infection (Dains et al., 2019).
Bone scan: To assess blood flow and bone formation or destruction. Performing this scan can help reveal inflammatory and infiltrative processes and occult fractures (Dains et al., 2019). Bone scan can detect and monitor an infection, fracture or bone disorder. A small amount of radioactive material is injected into the bloodstream and collects in the bones particularly in areas with some abnormalities.
Discography- involves injecting a contrast dye into a spinal disc thought to be causing low back pain. The fluid’s pressure in the disc will reproduce the person symptoms if the disc is the cause. The dye helps to slow the damage area on CT scans taken following the injection ()
Bone mineral density: This is a radiograph test done to assess the amount of calcium in the bone (Dains et al., 2019).
Electromyography ( EMG): This diagnostic procedure is done to assess the health of muscles and the nerve cells that control them (Vialle et al., 2015).
Magnetic resonance imaging (MRI): This is done to visualize and evaluate soft tissue details, such as tumors, spinal code pathologies, and disk herniations (Dains et al, 2019).
Computerized tomography (CT) can show soft tissue structures that cannot be seen on conventional x-rays, such as disc rupture, spinal stenosis, or tumors (Dains et al, 2019).
X-ray imaging can show broken bones or an injured or misaligned vertebra (Dains et al, 2019).
Urinalysis: This is done to assess the kidneys and metabolic functions, as well as to rule out any visceral causes of back pain like pyelonephritis (Dains et al., 2019).
Agency for Healthcare Research and Quality (AHRQ) guidelines is important to implement as it helps hospitals rework their discharge processes to reduce readmissions by determining patients’ needs and carefully designing and communicating discharge plans. Hospitals using these tools have seen a 30 percent reduction in hospital readmissions and emergency rooms visits (AHRQ, 2018).
Differential Diagnoses
Primary Diagnosis/Presumptive Diagnosis: Herniated disk
Herniated Disk: This occurs when the root of a nerve is irritated causing acute lower back pain that radiates down the buttock and below the knee (Vialle et al., 2015).
Lower Back Strain: This occurs when the back structures like the ligaments and muscles get inflamed from being overused (Will et al., 2018).
Spinal Fracture: This is evident as a result of a major trauma or impact to the back from a fall or strenuous lifting. Immobilizing the affected area to obtain an urgent radiograph is important to avoid further damage (Will et al., 2018).
Osteomyelitis: Is an infection of the bone. When one part of the body is infected, it can spread to through the bloodstream and into the bone.
Cauda Equina Syndrome: This happens when there’s a compression of the S1 nerve root causing constant back pain. This condition may also cause some limitations with forward flexion.
The two nerve most commonly pinched in the lower back are L5 (Lumbar 5) and L1 Sacral 1. Pinched nerve at L5. The L5 never supplies the nerves to the muscles that raise the foot and big toes and consequently, impairment of this nerve may lead to weakness in these muscle. The lower back includes the five vertebrae (referred to as L1-L5) in the lumbar region, which supports much of the weight of the upper body. The spaces between the vertebrae are maintained by round, rubbery pads called intervertebral discs that act like shock absorbers throughout the spinal column to cushion the bones as the body moves. Bands of tissue known as ligaments hold the vertebrae in place, and tendons attach the muscles to the spinal column. Thirty-one pairs of nerves are rooted to the spinal cord and they control body movements and transmit signals from the body to the brain (Will et al., 2018).
The physical examination and Maneuvers Perform
The provider will perform a physical exam and perform maneuvers that will include: The FABER maneuver is one of the maneuvers that will be used such as flexion, abduction, external rotation at the hip. Place the patient in the supine position. Flex the leg and put the foot of the tested leg on the opposite knee. The motion is that of flexion abduction, external rotation at the hip. Slowly press down on the superior aspect of the tested knee joint lowering the leg into further abduction. The test result is positive if there is pain at the hip or sacral joint or if the leg cannot lower to the point of being parallel to the opposite leg (Dains et al., 2019)
Gait and Posture- Observation of the patient’s walk and overall posture is suggested for all patients with low back pain. Scoliosis may be functional and may indicate underlying muscle spasm or neurogenic involvement (Bratton, 2016)
Range of motion- The examiner should record the patient’s forward flexion, extension, lateral flexion and lateral rotation of the upper torso. Pain with forward flexion is the most common response and usually reflects mechanical causes. If pain is induced by back extension, spinal stenosis should be considered. Unfortunately, the evaluation of spinal range of motion has limited diagnostic use, although it may be helpful in planning and monitoring treatment (Bratton, 2016)
Palpation or Percussion of the spine- Point tenderness over the spine with palpation or percussion may indicate fracture or an infection involving the spine. Palpating the paraspinous region may help delineate tender areas or muscle spasm. Palpate for tenderness over bone and soft tissues. Perform an abdominal examination to identify any masses, and consider a rectal examination. Cauda equina syndrome may present with: Low back pain, Pain in the legs, Unilateral or bilateral lower limb motor and/or sensory abnormality, Bowel and/or bladder dysfunction with saddle and perineal anaesthesia and Loss of anal tone and sensation (Bratton, 2016)
Heel-Tow walk and Squat and Rise- A patient unable to walk heel to toe, and squat and rise may have severe cauda equina syndrome or neurologic compromise (Bratton, 2016)
Palpation of the Sciatic Notch- Tenderness over the sciatic notch with radiation to the leg often indicates irritation of the sciatic nerve or nerve roots (Bratton, 2016)
Straight Leg raising Test- With the patient in the supine position, each leg is raised separately until pain occurs. The angle between the bed and the leg should be recorded. Pain occurring when the angle is between 30 and 60 degrees is a provocative sign of nerve root. Bending the knee while maintaining hip flexion should relieve the pain, and pressure in the popliteal region should worsen it (popliteal compression test). If placing the knee back in full extension during straight leg raising and dorsiflexing the ankle also increase the pain (Lasègue’s sign), nerve root and sciatic nerve irritation is likely (Bratton, 2016)
Reflexes and motor and sensory testing- Testing knee and ankle reflexes in patients with radicular symptoms often helps determine the level of spinal cord compromise. An altered knee or ankle reflex alone does not suggest the need for invasive management because this finding is generally transient and fully reversible. Weakness with dorsiflexion of the great toes and ankle may indicate L5 and some L4 root dysfunction. Sensory testing of the medial (L4), dorsal (L5) and lateral (S1) aspects of the foot may also detect nerve root dysfunction (Bratton, 2016)
Neurovascular examination- A thorough examination of sensation, tone, power and reflexes should be performed. Always consider the possibility of acute spinal cord compression, which is a neurosurgical emergency. All peripheral pulses should also be checked, as vascular claudication in the upper and lower limbs (Yoo, McIver, Hiratzka & 2018).
Medications commonly used for the treatment of acute low back pain include aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen and, possibly, muscle relaxants. Patients taking opioid analgesic drugs, often used in the first few days after the development of acute low back pain, do not return to full activity sooner than patients taking NSAIDs or acetaminophen.16 Muscle relaxants are more effective than placebo but no better than NSAIDs in relieving acute low back pain. Oral corticosteroids and antidepressants do not appear to be effective in patients with acute low back pain, and their use is not recommended (Bratton, 2016)
References
Agency for Healthcare Research and Quality: A Profile. Content last reviewed March 2018. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/cpi/about/profile/index.html
Bratton, R. L. (2016, November 15). Assessment and management of acute low back pain. AAFP American Academy of Family Physicians. https://www.aafp.org/afp/1999/1115/p2299.html#afp19991115p2299-b8
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Vialle, L. R., Vialle, E. N., Suárez Henao, J. E., & Giraldo, G. (2015). LUMBAR DISC HERNIATION. Revista brasileira de ortopedia, 45(1), 17–22. doi:10.1016/S2255-4971(15)30211-1
Will, J.S., Bury, D.C., Miller J.A. (2018). Mechanical low back pain. Community Hospital, Fort Benning, Georgia. Am Fam Physician; 98(7):421-428.
Yoo JU, McIver TC, Hiratzka J, et al; The presence of Waddell signs depends on age and gender, not diagnosis. Bone Joint J. 2018 Feb100-B(2):219-225. doi: 10.1302/0301-620X.100B2.BJJ-2017-0684.R2.
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