Episodic/Focused SOAP Note
Patient Information:
JK 42y white male
CC: Lower back pain for 1 month
HPI : The patient is a 42 year old white male who presents to the clinic with complaint of lower back pain for the last month that sometimes radiates into his left leg. The patient states the pain started a month ago after starting a job as a truck driver. He stats the pain is sharp, stabbing and radiates down the back of his left buttock into his posterior thigh. The pain is rated 8/10 when it flares up but is normally 2/10 while sitting or driving. Walking around makes the pain worse and lying down makes the pain tolerable, the patient states the pain is worse with bending and lifting. He states he took some tramadol that was prescribed for his migraines but he does not get relief. The patient states he has tried heating pads and a lumbar support pillow with minimal improvement in symptoms. The patient denies other symptoms with this pain, denies numbness or tingling in his foot or lower leg, denies bowel or bladder dysfunction and denies any significant injury that he can relate to this pain.
Current Medications :Ultram 50mg po every 6 hours as needed for pain (prescribed for migraines), takes twice a day for the last 2 weeks
SalonPas pain patches, one patch to his lower back in the morning for back pain used twice in last month with minimal improvement in symptoms
Baby aspirin 81mg po daily as prescribed by his GP for “my heart” has been taking for 5 years
Allergies: Penicillin-childhood allergy, unsure of reason for allergy “mom says it makes me cough”
PMHx : Pt is up to date on vaccines, last tetanus 2020 and flu shot in 2021. The patient has a history of migraines triggered by cleaning product fumes, denies ever having surgery however has had stitches multiple times. The patient denies major illnesses and states “gotta be healthy to drive truck”. The patient was adopted and denies knowledge of family medical history however he claims to have “healthy” lifestyle choices and maintains his weight in a healthy range. Denies ever being hospitalized and states he gets all his preventative care yearly.
Soc Hx : The patient drives a semi-truck for a major store and has been driving truck for 10 years. He obtained a
Discussion Assessing Musculoskeletal Pain certificate for his CDL. His free time is used to coach little league baseball and adopts stray cats. He is active in his church and volunteers his time in nursing homes teaching sign language to the hearing impaired. The patient lives at home with his adoptive mother and father and no one in the household smokes. The patient denies illicit drug use and denies sexual history. He states he always uses a seat belt and never breaks the speed limit. He denies using tobacco products but admits to making his own moonshine which he sells in Alabama gas stations. The patient has never been married and does not have children, his parents are very supportive and pay all of his expenses so that he can donate his income to animal shelters. The patient expresses fear that his back pain will paralyze him and make him quit his job.
Fam Hx : The patient was adopted and has no knowledge of his parents or siblings. He does not have children and does not have biological relatives to his knowledge.
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ROS :
GENERAL: Admits to a small weight gain over the last 2 weeks which he attributes to increase in appetite. Denies fevers, chills, weakness and reports feeling more tired than usual due to the inability to sleep comfortably at night. Denies other symptoms of illness.
HEENT: Head is reported to be nontender and without obvious deformity, he denies head injury and states his last migraine was 2 years ago. Vision is clear and 20/20 per patient without correction and he denies blurry vision, sclerae is white with no redness noted. Ears are clear of obstruction and patient reports his hearing is “excellent”, Denies cold like symptoms and denies seasonal allergies, denies sinus pain. Denies sore throats or swelling.
SKIN: Denies rashes or abnormal moles, skin is dry and pink with 1st degree sunburn to left forearm from driving. Multiple scars to lower legs from childhood injuries.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema. Denies shortness of breath, denies edema to lower extremities or pain in calf area.
RESPIRATORY: Denies shortness of breath, cough or sputum. Respirations are unlabored and lung sounds clear in all fields.
GASTROINTESTINAL: reports increase in hunger for 2 weeks but patient also reports he has been more sedentary and eats when he is bored. Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. Patient reports bowel movements are soft and regular with no constipation.
GENITOURINARY: denies frequency or odor of urine, pt denies urinary hesitancy or loss of bladder control.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness but reports a burning “electric” sensation in the left hip/leg area radiating to the left buttock and down the back of his left thigh. No change in bowel or bladder control.
MUSCULOSKELETAL: reports a month of lower back pain that sometimes radiates to his left lower back. Pt is ambulatory and reports a slight limp when his back “flares up” on exam pt gait is steady and pt states he is able to move all extremities without difficulty.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
O.
Vitals: 125/77, hr 78, rr 14,oxygen 99% room air, temp 98.0 oral, 6’0 weight 199 General: The patient is slowly ambulatory into the exam room and appears pleasant. He denies other complaints besides those in the HPI and chief complaint. The patient sits gingerly and no limp is observed, appears to move all extremities without problems. The patient appears well groomed, with warm pink skin and is pleasant to talk to, he is alert and oriented x 4 and makes jokes with provider. Somewhat tense expression and mannerisms, when asked to stand or change positions. The patient is nervous when telling his complaint however he is alert and a good historian.
Neurological: patient is oriented x 4, PERRLA and all extremities with full sensation denies numbness or tingling in extremities. Hand grasps are equal and reflexes upper and lower intact.
Cardiovascular: S1 and S2 auscultated no gallups rubs or murmurs heard, pulses 3+ in all 4 extremities and no edema noted to extremities or facial area. No JVD observed and capillary refill in all fingers and toes less than 3 seconds. Bilateral carotids auscultated with no bruit and no thrill palpated. No signs or symptoms of AAA (no bruit auscultated over aorta)
Respiratory: Resps are unlabored all lung sounds clear to auscultation and no adventitious lung sounds heard. No cough noted.
Skin: No bruising noted to either flank, no ecchymotic areas to back or hip area
Musculoskeletal: Inspection of back reveals no abnormalities, palpitation does not produce pain or trigger symptoms. The patient is asked to touch his toes which he does with mild pain and reports pain is worse when straightening back up. Patient is able to squat and stand on tiptoes without problems L3 to S1 dermatomes palpated for sensation and pain and exam is unremarkable. Babinski sign is negative, deep tendon reflexes in bilateral lower extremities shows no deficit. Sitting knee extension causes the patient pain in lower extremity.
Psychiatric: patient admits to anxiety over the idea of having “back problems” and the possibility of not being able to do his job in the future. No diagnosis of psychiatric problems.
Diagnostic results : Patient will need spinal xrays to evaluate for herniated disks, spinal fractures and tumors. MRI may be helpful if the problem continues, if the patient was being considered for a tumor or an infection then an ESR or CRP as well as CBC to rule out infectious processes. If an aneurysm was suspected an abdominal ultrasound or a CT of the abdomen could be done.
A .
Differential Diagnoses
Sciatica-
Sciatica is a clinical diagnosis based on symptoms of radiating pain in one leg with or without associated neurological deficits on examination (Jenson et.al 2019) Extended straight leg raise is helpful diagnosing sciatic pain (Pesonen, 2021).
Cauda equina syndrome
This can be ruled out with the ability to control bladder and bowel functions as well as lack of numbness in the “saddle” area (Long 2021)
Vertebral compression fracture
this can be ruled out with spinal xrays and a history of osteoporosis or injury recollection as well as tenderness to palpation
Lumbar muscle strain
Palpation of the lumbar area as well as negative xrays of the back, and negative CT scan, also the relief from muscle relaxers and heat may indicate muscle strain. Pain that is relieved with lying down and resting.
Dissecting AAA
Review CT scan for abnormalities as well as clinical presentation of pallor, tachycardia, diaphoresis
References
Jensen, R. K., Kongsted, A., Kjaer, P., & Koes, B. (2019). Diagnosis and treatment of
sciatica. bmj , 367 .
Long, B., Koyfman, A., & Gottlieb, M. (2020). Evaluation and management of cauda equina
syndrome in the emergency department. The American Journal of Emergency
Medicine , 38 (1), 143-148.
Pesonen, J., Shacklock, M., Rantanen, P., Mäki, J., Karttunen, L., Kankaanpää, M., … & Rade,
M. (2021). Extending the straight leg raise test for improved clinical evaluation of sciatica: reliability of hip internal rotation or ankle dorsiflexion. BMC Musculoskeletal Disorders , 22 (1), 1-8.
AssignWeek8.discussion soap.brinson r.doc (53.5 KB)
Week 8 Ankle Pain
Episodic/Focused SOAP Note Template
Patient Information: CC, 46, F, Caucasian
S.
CC “Ankle pain”
HPI : Cheyenne Calhoun is a 46-year-old Caucasian female who presents to the clinic today complaining of pain in her right ankle for the last 3 days. The patient states her ankle is uncomfortable to walk on, but she is still able to bear weight. The patient states that her discomfort began while running while playing soccer when she heard a pop sound. She states her pain is relieved by rest and exacerbated by walking and bearing weight for extended periods of time. Patient currently rates her pain at a 2 out of 10 at rest, and a 4 out of 10 with ambulation.
Current Medications :Levothyroxine 50mcg
Tylenol 650mg q8 PRN pain
Allergies: Denies medication allergies, food allergies, seasonal allergies, and allergies to latex.
PMHx : Hypothyroidism- dx 2012.
T-Dap 8/17/2021
Influenza Oct/2021
Soc Hx : Cheyenne is currently employed a stay a live-in caregiver for her adoptive brother Axyl. She has been divorced for the last 5 years, has no children, and states she moved to be closer to family and take care of her brother who has been diagnosed with stage 3 esophageal cancer. Cheyenne enjoys playing soccer on the weekends for a local team when her mother comes to town to take over care of her brother. She states she has never smoked, does not drink alcohol, and drinks very little caffeinated coffee. Cheyenne states she has an involved support system at home, who helps her care for not only her needs but helps alleviate additional stressors that arise as her brother’s main caregiver. She states she has active smoke detectors in her home and does not use her cell phone while driving.
Fam Hx : One adoptive brother- stage 3 esophageal cancer
One sister – hypertension, hypothyroidism
Mother- Age 68, hypertension
Father, deceased age 35, motor vehicle accident
Maternal Grandmother- Age 91, glaucoma
Maternal Grandfather- deceased age 82, complications of influenza, hx of Type 2 diabetes, glaucoma, cardiac stent x2
Paternal Grandmother – Age 86, COPD diagnosed 30 years prior, long term oxygen for past 6 years. Hypertension
Paternal Grandfather- Deceased age 72, industrial accident with belt sander.
ROS : cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head : EENT : etc. You should list these in bullet format and document the systems in order from head to toe.
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies blurred vision, visual loss, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, congestion, sneezing, runny nose or sore throat.
SKIN: Denies itching or rash.
CARDIOVASCULAR: Denies chest discomfort, pressure, or pain. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies nausea, vomiting or diarrhea, anorexia. No abdominal pain or blood in stool.
GENITOURINARY: No burning on urination. Denies Pregnancy. Last menstrual period, 4/17/2022.
NEUROLOGICAL: Denies headache, dizziness, numbness, paralysis, syncope, ataxia, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Pain with ambulation on the right foot. States range of motion is mildly reduced. Positive history of injury.
HEMATOLOGIC: Denies anemia, bleeding, or bruising.
LYMPHATICS: No history of splenectomy. Denies enlarged nodes.
PSYCHIATRIC: Denies history of anxiety or depression.
ENDOCRINOLOGIC: Denies reports of sweating, heat, or cold intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, eczema, rhinitis, or hives,
O.
Vital signs: B/P 132/72, left arm, sitting, regular cuff; P 62 and regular; T 37.0 Orally; RR 16; non-labored; Wt: 141 lbs, Ht: 5’5
General: A&O x3, NAD, appears mildly uncomfortable
HEENT: PERRLA, EOMI, oronasopharynx is clear
Neck: Carotids no bruit, thyromegally, or jvd
Chest/Lungs: Lungs are clear throughout all lung fields, no advantageous breath sounds.
Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial
ABD: normoactive bowel sounds throughout all quadrents. No tenderness with light and deep palpation. Spleen not palpable. Kidneys nonpalpable.
Genital/Rectal: patient declined for this exam
Musculoskeletal: Symmetrical muscle development in bilateral extremities. Gait during movement is slowed with the placement of foot rolling to the inside of the foot. Grips pushes and pulls are 5/5 throughout all groups.
Neuro: Cranial nerves grossly intact, speech is clear, cranial nerves II-XII grossly intact.
Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes
Diagnostic results : Xray- right ankle negative for gross fracture. The appearance of mild
swelling along a lateral side of the ankle extending through the posterior talofibular ligament.
MRI – mild (grade 1) tearing to peroneal tendon
Laboratory- Vitamin D level 22.
A .
1. Peroneal tendon injury – Peroneal tendon disorders account for a large portion of posterolateral complaints of the ankle and are linked to ankle instability and predispose patients to anatomic abnormalities (van Dijk et al., 2019). An injury to this area would result in a popping sound in the ankle that is accompanied by pain and stiffness. This is the most likely cause of injury. This injury can also involve mild tearing of one or both of the peroneal tendons caused by repeat or chronic damage based on the patient’s active sports history. Further confirmation can be made by MRI, ruling out of fracture by using xrays. Other symptoms which should be explored are the uneven gate when walking noted, rest should be advised, but if the normal gate is not restored in a few weeks with rest, referral to an orthopedist should be considered.
2. Tendon sublaxation- Tendons that have become injured and may be free to slip out of the normal position may result in a relocation snap from the tendon relocating back into its proper position (eOrthopod, 2015). This injury is common in runners and accounts for the discomfort and popping sound within the ankle.
3. Inversion Ankle Sprain- Occurs when the foot is forced into an inversion position beyond ligament and muscular control. Commonly causing ligament failure. This diagnosis is considered due to being one of the most common injuries to high-intensity athletes (Rehab My Patient, 2017) .
4. Osteochondral lesion- Present in 50-70% of ankle sprains and fractures, these lesions are due to injuries to the cartilage at the ends of bones within the ankle. These lesions can cause a clicking or locking of the ankle and may require surgery (Yetman, 2020).
5. Ankle Fracture- Fracture or microfractures of the bones within the ankle. This diagnosis should be included due to the patient’s vitamin D level, predisposition to bone fracture, and potential for overuse of ligaments placing patient as higher risk of instability injury (Lambert et al., 2020).
Primary Diagnoisis – Peroneal tendon injury
References eOrthopod. (2015). Peroneal tendon subluxation . Orthogate. https://www.orthogate.org/patient-education/ankle/peroneal-tendon-subluxation
Lambert, L.-A., Falconer, L., & Mason, L. (2020). Ankle stability in ankle fracture. Journal of Clinical Orthopaedics and Trauma , 11 (3), 375–379. https://doi.org/10.1016/j.jcot.2020.03.010
Rehab My Patient. (2017, July 25). Inversion sprain of the ankle . Rehab my patient. https://www.rehabmypatient.com/ankle/inversion-sprain-of-the-ankle
van Dijk, P. D., Kerkhoffs, G. J., Chiodo, C., & DiGiovanni, C. W. (2019). Chronic disorders of the peroneal tendons. Journal of the American Academy of Orthopaedic Surgeons , 27 (16), 590–598. https://doi.org/10.5435/jaaos-d-18-00623
Yetman, D. (2020, April 27). Ankle popping or cracking: Causes and remedies . Healthline. https://www.healthline.com/health/ankle-popping#causes
Week 8 NURS 6512-26 Case 1: Back Pain Episodic/Focused SOAP Note Template
Patient Information: AB, 46, Male, Latino/Cuban
S.
CC : “My lower back is hurting so bad that I can barely walk for no reason and it won’t go away.”
HPI : Alan Baca is a 46-year-old Cuban-American male who presents today for low back and buttock pain, spasms, and occasional left leg radiation that began approximately one month ago. He states no trauma or injury related to onset of symptoms. The pain is “constant aching” of 5/10 with “stop-in-your-tracks” spasms that are 8/10 especially after any prolonged periods of driving. At least 4 or 5 times a day he experiences shooting “electric shocks” that travel down his left leg into his calf. He states that at first ibuprofen worked “a little” but it no longer is effective. Ice and heat were tried and are no longer effective. Rest is minimally effective. The worst episode was reported yesterday after kicking away his pet’s small toy on the floor in front of him “bringing me to tears” and considered going to the hospital at a 9/10. He reports that getting dressed takes twice as long as usual due to the pain and that he avoids many activities that he fears could cause spasms like driving.
Current Medications
Loratadine 10 mg PO daily for seasonal rhinitis (last taken 04/20/22 at 08:00)
Diphenhydramine 25 mg Take 2 PO HS PRN insomnia (last taken 2100 04/19/22)
Ibuprofen 200 mg Take 3- or 4-tabs PO Q 6 hours PRN pain (last taken 04/20/22 at 08:00)
Acetaminophen 500 mg Take 2 tabs Q6 hours PRN pain (last taken at 04/19/22 at 23:00)
Allergies: Spring seasonal allergies to pollen (rhinitis)
No latex allergy, no known drug allergy, or food allergy
PMHx :Immunizations: PPD 12/13/21 and 01/11/22, Tetanus 10/10/20, Declined COVID vaccine and influenza
Medical: COVID hospitalization x2 days May 2020, kidney stone 2016
Surgical: lithotripsy 2016
Soc Hx : Mr. Alan Baca is a 46-year-old Cuban-American married male. He AB reports use of a seatbelt when driving, changes batteries in smoke detectors every April, and purchased a new fire extinguisher for his kitchen this year. AB reports a “comfortable lifestyle” in a safe middle-class neighborhood 15 minutes away from downtown Acme. AB has been married for the past 20 years and has two adult children who live in the same town. He states that he is only sexually active with his spouse and denies any unsafe feelings at home. He states a close relationship with wife, children, and extended family in the area. He completed high school and is full-time employed as a construction foreman for a family-owned company for the past ten years. He reports eating three “big” meals a day. All meals include meat; reports some concern with his weight. Breakfast is often 3 scrambled eggs with cheese and bacon. Sandwiches that he takes to the work sites are often foot long. He states that his wife cooks steak, burgers, and chicken often at dinner accompanied by a vegetable. He and his family attend Catholic services on Sunday’s and some additional religious events. AB enjoys boating, fishing, and waterskiing during the summer and reads autobiographies in his downtime after work. AB was a smoker from age 15 to 25 when he was able to quit “cold turkey” after his father died from lung cancer. AB does not drink and reports no history of prescription or street drug use.
Fam Hx :Paternal Grandfather: deceased; prostate cancer at age 57.
Paternal Grandmother: alive/well; hypertension age 82.
Maternal Grandfather: alive age 84 with hypertension, migraines, DDD with disability/wheelchair mobility.
Maternal Grandmother: alive age 67 morbid obesity and hypothyroidism.
Father: deceased; lung cancer at age 46.
Mother: Alive at 62 with hypothyroidism
Daughter: Alive at 18 with no significant health history.
Daughter: Alive at 21 with no significant health history.
ROS :
GENERAL: Denies weight loss, fever, vomiting, shaking, chills, weakness, or fatigue.
HEENT: No blurred or double vision. No runny nose of or bleeding, no sore throat, no headache.
SKIN: No rash, bruising, masses, or itching.
CARDIOVASCULAR: No chest pain, palpitations or edema.
RESPIRATORY: No pain, shortness of breath, cough, wheezing, or sputum.
GASTROINTESTINAL: No nausea, vomiting, or diarrhea. No abdominal pain, blood, or swallowing difficulty.
GENITOURINARY: Burning pain or urine stream change.
NEUROLOGICAL: No headaches, No change in bowel or bladder control. No numbness. Positive for tingling in the left lower extremity. Exacerbation of pain in the left leg when extended.
MUSCULOSKELETAL: Muscle spasms, back pain radiating down left leg, no joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No depression, anxiety, or thoughts of suicide/self-harm.
ENDOCRINOLOGIC: No sweating, cold or heat intolerance. No excessive thirst or urination.
ALLERGIES: seasonal rhinitis.
O.
Physical exam :Height: 5’11 Weight:230 BMI: 32.1 VS: 126/80, 80, 16, 98.4, 98% RA
General: Pleasant but serious demeanor, appears stated age. Difficulty with getting on exam table due to pain. Groomed/neat appearance. Alert and oriented x3.
Head: Exam deferred.
Eyes: Exam deferred.
Ears: Exam deferred.
Nose: Exam deferred.
Throat/mouth: Exam deferred.
Neck: Exam deferred.
Chest: Exam deferred.
Heart: No chest wall deformity. RRR, S1 and S2 heard with no murmurs, rubs, or gallops. JVD 3 cm at 30 degrees without bruits or cyanosis.
Abdomen: Rounded. Auscultation without bruit. Palpation without masses.
Back: Neck and cervical spine have no deformities or signs of inflammation. Within normal limits curvature of cervical, thoracic, and lumbar spine. Bony features of shoulders and hips are of equal height bilaterally and non-tender. Smooth but guarded gait. On palpation C-7 -L5 are palpable and midline. Tenderness is only present with deep palpation to L-4/ L-5. Maneuvers provided pain with straight leg extension and mild relief to spasms of low back with knees to chest.
Extremities: No edema, cyanosis, or erythema to upper or lower extremities. Pulses are 2 of 4 for bilateral femoral, popliteal, posterior tibial, and dorsalis pedis.
Neuro: Alert and oriented x 3. Sensation is intact with deep, light, and sharp touch throughout. Gait slow, steady, and intact. Memory intact for short and long term with appropriate mood/affect. Reflexes diminished on the left Reflexes tested and are 2+ and symmetric at the biceps and triceps. Knees, ankles, plantar are not symmetric with the left noted at a +1 and right at +2. There is no pronator drift of out-stretched arms. Muscle tone and strength is symmetric bilaterally.
Skin: Warm, moist, no rashes or moles, +1 turgor
Diagnostic results : Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
UA with micro, CBC, BMP, US, MRI, CT, FAIR test/maneuver, Lasegue test (straight-leg test)
A .
Differential Diagnoses Radiculopathy-sciatica: consistent w/nerve root irritation from herniated disc, degenerative disk disease, or arthritis. Features: numbness, tingling, or muscle weakness to associated areas with that nerve. No numbness or muscle weakness are noticed at this time however, positive to tingling and reflexes that are affected are supportive of this condition. Radiculopathy causes radiating pain frequently which is present in this case. That pain is often sharp or burning which is similar to the “zings” stated by AB. A straight-leg test provides easy feedback about sciatic involvement that can be easily preformed in the office exam room (Rao et al,. 2018).
Piriformis Syndrome : Irritation caused by a piriformis condition often directly affects the sciatic nerve that mimics a herniated disc pain. The conditions of extremity numbness, weakness, and tingling are a result of the impacted nerve that has a different origin than radiculopathy and should be addressed differently. The FAIR test or maneuver can help substantiate this potential diagnosis and should be considered before more expensive options however, MRI’s offer a more detailed image of this condition (Tawa et. al., 2017).
Urolithiasis : Severe flank and groin pain are common presentations with this condition. Mr. AB has known history of kidney stone development and procedure. He will provide a urine sample and other labs that could indicate conditions such as infection and blood that are supportive of this diagnosis. The lack of evidence of infection, increased urine stream concerns, pain that travels via the urine pathway versus down the leg are not suggestive of this diagnosis. Should symptoms more closely resemble urolithiasis than in this case an US is first choice followed by CT scan would be indicated to identify stones (Turk et al., 2016).
Osteomyelitis/Diskitis: Unresolving low back pain can be a result of infection originating in the structural bodies of the low back. AB is not febrile or exhibiting other signs or symptoms of infection but labs are supportive to definitively rule out this possibility. Age greater than fifty and immune compromised conditions are risk factors requiring labs and MRI to rule-out (Ledbetter et al., 2015).
Metastatic cancer : Metastatic disease from the prostate, lung, thyroid, and kidney accounts for 80 percent of skeletal metastases which cause the type of pain the AB faces. AB does not have known history of cancer which moves this diagnosis down the list but MR imaging would show metastatic disease (Wheeler et. al., 2022).
P.
NA
References
Ledbetter, L., Salzman, K., & Shah, L. (2015). Imaging psoas sign in lumbar spinal infections: Evaluation of diagnostic accuracy and comparison with established imaging characteristics. American Journal of Neuroradiology , 37 (4), 736–741. Retrieved April 20, 2022, from https://doi.org/10.3174/ajnr.a4571
Rao, D., Scuderi, G., Scuderi, C., Grewal, R., & Sandhu, S. (2018). The use of imaging in management of patients with low back pain. Journal of Clinical Imaging Science , 8 , 30. Retrieved April 19, 2022, from https://doi.org/10.4103/jcis.jcis_16_18
Tawa, N., Rhoda, A., & Diener, I. (2017). Accuracy of clinical neurological examination in diagnosing lumbo-sacral radiculopathy: A systematic literature review. BMC Musculoskeletal Disorders , 18 (1). Retrieved April 20, 2022, from https://doi.org/10.1186/s12891-016-1383-2
Türk, C., Petřík, A., Sarica, K., Seitz, C., Skolarikos, A., Straub, M., & Knoll, T. (2016). Eau guidelines on diagnosis and conservative management of urolithiasis. European Urology , 69 (3), 468–474. Retrieved April 19, 2022, from https://doi.org/10.1016/j.eururo.2015.07.040
Wheeler, S. G., Wipf, J. E., Staiger, T. O., Deyo, R. A., & Jarvik, J. G. (2022). Evaluation of low back pain in adults (Up to Date) [Literature Review]. Medi Media.
Subjective CC: Lower back pain
HPI: Hispanic male patient JM, age 42, presented to the clinic today complaining of severe lower back pain over the past month. Periodically, the pain travels along his left leg. He felt a sharp, throbbing pain in his left lower leg, along with a tingling feeling. He said the ache in his back was an eight out of ten. He feels more discomfort when he lifts heavy objects, bends, or sits for lengthy periods of time. He says over-the-counter ibuprofen helps a little.
Current Medications: OTC Ibuprofen 400mg Q4hrs as needed for pain.
Claritin 10mg daily for allergies
Lisinopril 5mg daily for hypertension
Allergies: No known drug allergy; environmental allergies: Pollen (Reaction- sneezing and watery eyes).
PMHx: Medical history includes hypertension 5 years ago. No hospitalizations. His vaccinations are all current.
Past surgical Hx: No surgical history reported.
Social Hx: JM has a high school diploma and is employed as a bricklayer for a local construction company. He is married and resides in a three-bedroom home with his wife and 10-year-old son. For the last ten years, he has been smoking one pack of cigarettes per day. He denied consuming alcohol or using illegal substances. Because of his back pain, he refuses to exercise on a regular basis. He follows a healthy diet that includes fruits and vegetables.
Family Hx: Mother is 65 years old, living, and has been diagnosed with high blood pressure and high cholesterol. His father is 70 years old, living and suffering from hypertension and benign prostatic hyperplasia. Grandpa on the mother’s side passed away at age 64 due to heart attack complications. Maternal grandmother died at age 73 from asthma and diabetes related problems. His paternal grandfather passed away at age 71 due to COPD-related illnesses. His paternal grandmother was 55 years old when she passed away from lung cancer. At the age of 45, one sibling was diagnosed with multiple sclerosis. One healthy kid of 10 years old.
ROS:
General: Reported intermittent tingling and numbness in the left limb. No reports of fever, chills, or weight loss.
HEENT: Denies head injury, blurred vision, hearing loss. No changes in smell or taste reported. No complaints of epistaxis. No sore throat was reported.
Skin: No skin lesion, mole, or rash.
Cardiovascular: No reports of heart murmur, chest discomfort, and irregular heartbeat. No edema in the extremities.
Respiratory: No reports of cough or dyspnea.
Neurological: Denies migraines, fainting, or convulsions. No reports of coordination problems.
Musculoskeletal: Pain in the lower back and sometimes in the left leg. Denies that other parts of the body have swollen joints or muscle pain.
Hematologic/Lymphatic: Denies bleeding or bruising. Denies enlarged nodes or history of splenectomy.
Endocrine: No heat or cold intolerance reported. No c/o polydipsia or polyuria.
Objective Physical Exam: General: Patient is alert and oriented x3. He is calm and answers interview questions appropriately. He is well-nourished and well- developed. He reports weakness to the left lower extremity.
Vitals: BP- 145/88mmHg; HR- 90bpm and regular; Resp- 19bpm and regular; Temp- 98.5F orally; SPO2 99%R/A; Height- 5’8”; Weight- 166lbs; BMI- 25.2.
Skin: Turgor is good. No rashes or lesions.
HEENT: Head is normocephalic. PERRLA. Conjunctivae negative for exudate and hemorrhage. External auditory canal is patent. Ears are nontender and not swollen. Nares are patent. Nasal mucosa is pink without drainage. Oral mucosa is moist, pink with no lesions. No tonsillar swelling, no pharyngeal swelling.
Cardiovascular/peripheral Vascular: Presence of S1S2 heart sounds during auscultation; no murmurs. Heart rate regular rhythm. Peripheral pulses 2+ symmetrical bilaterally. No peripheral edema.
Respiratory: Chest symmetrical. No adventitious lung sound auscultated.
Gastrointestinal: Abdomen is symmetrical. Normoactive bowel sounds x four quadrants. Abdomen is soft, nontender. No palpable masses.
Musculoskeletal: Low back pain with flexion, extension, and twisting. Limited ROM to lower extremities. No sign of trauma to lower back.
Neurological: Alert and oriented x3. Appropriate affect and mood.
Diagnostic Test:
Complete blood count (CBC) to verify infection (high WBC count).
Erythrocyte sedimentation rate (ESR) to detect inflammation.
A computed tomography (CT) scan to detect unusual tissues and analyze the patient’s spinal status.
Imaging of the spinal cord and nerves using (MRI) magnetic resonance imaging (Dains et al., 2019).
Assessment Differential Diagnosis:
Lumber disc herniation (LDH): Lumbar disc herniation is defined as the movement of disc material (annulus fibrosis or nucleus pulposus) over the intervertebral disc area, causing low back and/or leg pain (Yang et al., 2022). It usually starts with lower back discomfort that spreads down one leg and is often followed by sensations of numbness or tingling in the lower leg. The symptoms of LDH correspond to the patient’s chief concern.Sciatica: Sciatica is characterized by radiating and tingling pain down the leg and lower back caused by inflammation or compression of the lumbosacral nerve roots (Jensen et al., 2019). Furthermore, sciatica is frequently brought on by a herniated spinal disk, excessive movement, or heavy lifting, according to Dains et al. (2019). The patient is overweight, and his job requires heavy lifting and recurrent movements, which may contribute to his lower back pain.Lumber Spinal Stenosis (LSS): Lumbar spinal stenosis (LSS) is a degenerative disc condition that causes the area encompassing the vertebrae’s neurovascular systems to narrow (Fishchenko et al., 2018). Symptoms of nerve inflammation or compression include discomfort and weakness or numbness in the legs. A history, physical examination, and imaging studies are used to make the diagnosis. The assessment should concentrate on leg or buttock pain while ambulating and stretching to alleviate symptoms (Chagnas et al., 2019).Piriformis Syndrome (PS): Muscle spasm in the piriformis and/or irritation of the sciatic nerve in the area are the root causes of piriformis syndrome, as stated by Siddiq & Rasker (2019). Physical examination, patient history, and imaging studies like x-rays are used to determine the diagnosis of PS. The authors indicated that the flexion-adduction-internal rotation test, the Pace sign, and the Freiberg techniques are used to identify individuals with PS. Pain and weakness by resisted abduction and external rotation of the hip while seated suggests signs of Pace. The Freiberg sign manifests as pain and weakness with passive forced internal rotation of the hip in a supine position.Lumbar spondylolisthesis: Low back pain, lower limb radiating pain, and sporadic neurogenic claudication are symptoms of lumbar spondylolisthesis, a degenerative condition of the lumbar spine (Wang et al., 2022). The patient’s symptoms match the above statement, too.
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