Back pain

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?

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Respond to this

#1

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:

R.E, 42-year-old African American male

Subjective

CC: “Lower back pain”

HPI: A 42-year-old black African American male who came to the clinic today for complaining of lower back pain which he reported started a month ago. The patient stated that the pain sometimes radiates to his left leg.

 

Location: Lower back

Onset: One month ago

Character: Sharp, constant, radiating to left leg

Associated signs and symptoms: None

Timing: Starts when at work

Exacerbating/ relieving factors: Any movement. Ibuprofen helps to relief the pain temporarily.

Severity: 7/10 pain scale

Medications:

Ibuprofen 200mg 3 tablets every 6 hours PRN for lower back pain.

Amlodipine 10mg daily for hypertension x1 years.

Allergies: No known drug allergy, no food allergy, no seasonal allergy and No known allergy to latex/rubber.

PMHx:

Hypertension diagnosed one year ago.

Influenza vaccine November of 2020.

Tdap vaccine 2018.

Pneumonia: Not yet had any pneumococcal vaccine.

Up to date on all childhood immunizations.

Past surgical history: None.

Social History: Mr. R.E is happily married with three children. He has a bachelor’s degree in medical laboratory and works in the hospital setting. Mr. R.E denies ever smoking, but he drinks Corona beer occasionally and during festive period with friends and family. He denies using any illicit drugs and the thought of suicidal ideation. He goes to the gym at least 1-2 times in a week and walk around his neighborhood to keep him physically active and healthy.  He loves dancing as a hobby and going for vacations with his family. The patient reported that he loves to maintain his activities of daily living and dress according to weather, as for his instrumental Activities of Daily Living he said he manages his finances and financial assets by paying his bills early. Mr. R.E loves his traditional African food and occasionally eat out. The patient reported that he keeps to safety measures by putting on his seatbelt and not texting while driving, he also reported having a working smoke detector and a security camera in his house. He has a good family support system for his wife and children. He sleeps 6-8 hours per night.

Family History:

Mr. R.E mother is still alive, age 70, has hypertension and type 2 diabetes mellitus. The Father is still living; he is 72 years old who has asthma.

Maternal grandmother deceased at age 78, had a stroke, she was diabetic.

Maternal grandfather, deceased at age 80, had prostate cancer.

Paternal grandmother deceased at age 70, from chronic obstructive pulmonary disease (COPD)

Paternal grandfather age 95, still alive had asthma.

Brother age 55 has type 2 diabetes mellitus.

Son, age 20, no health issues

Daughter age 16. No health issues.

Daughter 12, no health issues.

General:

The patient is alert and oriented to place, person, time and situation, appropriate judgement, well-nourished black, African American, dressed according to the weather, no distress noted, mild discomfort due to pain in his lower back. Emotional and behavioral needs are appropriate at the present time considering patient clinical condition, no current home stress or abuse.

HEENT: Denies itching eyes or any discharges. The patient said he uses glasses but does not use contact lens, he denies blurred vision. Denies ringing in his ears, hearing loss and discharged. Denies surgery to his ears and any recent infections. Denies epistaxis, discharges, congestion and sneezing, no loss or decreased sense of smell. Denies any sore throat or infection.

Respiratory: Elevated respiratory rate, 30/min.  Denies difficulty breathing, coughing, and wheezing. Denies secondhand smoking.

Cardiovascular/Peripheral Vascular: Denies chest pain, heaviness, or heart palpitation, denies shortness of breath and edema to both lower extremities.

Gastrointestinal: No complains of abdominal upset, no nausea or vomiting, have regular bowel movement. No changes in his appetite, no recent weight loss.

Genitourinary: Denies difficulty voiding, changes in voiding pattern and denies any penile discharge.

Neurological: Denies light headedness, fainting, seizure, vision changes or weakness to any side of his body. Denise changes in his thinking.

Skin: Negative for skin lesion, eczema, mole or rash and no skin changes.

Musculoskeletal: Lower back pain that radiates to his left leg. Denies joint stiffness or joint pain.

Hematologic: Denies any bleeding.

Endocrine: Denies cold or heat intolerance, excessive thirst, or urination, does not have any issue with his thyroid.

Psychiatry: Mr. R.E said he is fine, does not have any mental problems, denies depression, suicidal thought, patient states he loves his wife and his family and can never kill himself.

OBJECTIVE DATA:

Physical Examination:

Vital signs: BP 120/80 and regular, Heart rate: 65 and regular, Temperature: 98.2 F orally, Respiration 30; pulse oximetry 95% on room air, Weight: 160 lbs.; Height: 5’ 9”; BMI: 26

Neurological: Patient is alert and oriented to place, person, time and situation, appropriate judgement. Speech is clear, no facial drooping, no vision changes, follows movement. Understand clear, complex, comprehensive without cues or repetition.

Skin: Not pale, cyanosis or ashen. Dry and warm to touch. No tear and non-tainting.

Chest/Lungs: Tachypnea, the chest expands symmetrically, bilateral breath sounds are clear.

Heart/Peripheral Vascular: The heart rate is regular with a normal rhythm, S1and S2 sound heard. All peripheral pulses are strong and palpable +3, Negative edema to all extremities. Capillary refill is less than/equal to 2 seconds in all extremities and no cyanosis noted.

Abdomen: Soft and nondistended, bowel sound present and active in all four quadrants, no pain or rebound tenderness noted. Last Bowel movement was this morning.

Musculoskeletal: Lower back pain radiating to the left lower extremity. No evidence of trauma to affected area. Pain increases with flexion, extension, and twisting. Decreased mobility due to pain.

Diagnostic Tests:

Complete blood count (CBC) may point to infections or inflammation.

Erythrocyte sedimentation rate.

HLA-B27

Bone scans

X-Ray of the lumbar spine

Computerized tomography (CT) cervical spine/lumbar w/without contrast.

MRI of the lumbar spine

Assessment.

Differential diagnoses:

· Lumbar disc herniation (LDH): The intervertebral disc consists of an inner nucleus pulposus (NP) and an outer annulus fibrosus (AF). The central NP is a site of collagen secretion and contains numerous proteoglycans (PG), which facilitate water retention, creating hydrostatic pressure to resist axial compression of the spine. The NP is primarily composed of type II collagen, which accounts for 20% of its overall dry weight. In contrast, the AF functions to maintain the NP within the center of the disc with low amount of PG; 70% of its dry weight is comprised of primarily concentric type I collagen fibers. In LDH, narrowing of the space available for the thecal sac can be due to protrusion of disc through an intact AF, extrusion of the NP through the AF though still maintaining continuity with the disc space, or complete loss of continuity with the disc space and sequestration of a free fragment. It is estimated that this condition has approximately 75% heredity origin, other predisposing factors includes dehydration and Axial Overloading. The role of inflammatory signaling in producing nerve pain in LDH has been well-established. The primary signs and symptoms of LDH are radicular pain, sensory abnormalities, and weakness in the distribution of one or more lumbosacral nerve roots. CT myelography and MRI are used to detect this condition (Amin, R. M., Andrade, N. S., & Neuman, B. J. (2017).

· Lumbar spinal stenosis: Lumbar spinal stenosis is a narrowing of the spinal canal in the lower part of the back. Stenosis, which means narrowing, can cause pressure on the spinal cord or the nerves that go from the spinal cord to the muscles. Lumbar spinal stenosis (LSS) is most commonly due to degenerative changes in older individuals. This condition is most usually categorized as either primary when it is caused by congenital abnormalities or a disorder of the postnatal development, or secondary (acquired stenosis) resulting from degenerative changes or as effects of local infection, trauma, or surgery. Degenerative LSS anatomically can involve the central canal, lateral recess, foramina, or any combination of these locations. Central canal stenosis may result from a decrease in the anteroposterior, transversal, or combined diameter secondary to loss of disc height with or without bulging of the intervertebral disc, and hypertrophy of the facet joints and the ligamentum flavum. Fibrosis is the main cause of ligamentum flavum hypertrophy and is caused by accumulated mechanical stress, especially along the dorsal aspect of the ligamentum flavum. The symptom most ascribed to LSS is neurogenic claudication, also known as pseudoclaudication. Neurogenic claudication refers to leg symptoms containing the buttock, groin, and anterior thigh, as well as radiating down the posterior part of the leg to the feet. In addition to pain, leg symptoms can include fatigue, heaviness, weakness and/or paresthesia.  The symptoms can be unilateral or more commonly bilateral and symmetrical. The patient may suffer from accompanying back pain, but leg pain and discomfort are usually more troublesome. (Genevay, S., & Atlas, S. J. (2016).

· Lumbar strain/sprain: The lumbar spine, depends on soft tissues to help hold the body upright and support weight from the upper body. If put under too much stress, the lower back muscles or soft tissues can become injured and painful. Lumbar sprain occurs when ligaments are overstretched or torn. Ligaments are tough, fibrous tissues that connect bones together. The most common symptoms of a lumbar strain are sudden lower back pain, Spasms in the lower back that result in more severe pain and Lower back feels sore to the touch. In addition to a complete medical history and physical exam, diagnostic procedures for low back pain may include X ray, CT scan and MRI. (AANS, August 2020)

· Sciatica: Low back pain is one of the most frequently faced conditions in clinical practice. Low back pain has high direct and indirect costs and is a common reason for missed work. The sciatica also called radiculopathy, is affected, and caused by something pressing on the sciatic nerve that travels through the buttocks and extends down the back of the leg. People with sciatica may feel shock-like or burning low back pain combined with pain through the buttocks and down one leg. (AHRQ, November 15, 2016),

· Ankylosing spondylitis: Ankylosing spondylitis is a type of arthritis of the spine. It causes inflammation between the vertebrae, which are the bones that make up your spine, and in the joints between the spine and pelvis. In certain individual, it can affect other joints. This condition is common and more severe in men, it often runs in families, the cause is unknown, but it is likely that both genes and factors in the environment play a role. Early symptoms of this condition include back pain and stiffness. (MedlinePlus, December 7, 2020).

Reference

American Association of Neurological Surgeon, August 2020. Low Back Strain and Sprain.

Retrieved from ans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Low-

Back-Strain-and-Sprain#:

AHRQ, November 15, 2016) Noninvasive Treatments for Low Back Pain: Current State of the

Evidence. Retrieved from https://effectivehealthcare.ahrq.gov/products/back-pain-

treatment/clinician

 

Amin, R. M., Andrade, N. S., & Neuman, B. J. (2017). Lumbar Disc Herniation.

Current review in musculoskeletal medicine, 10(4), 507–516.

https://doi.org/10.1007/s12178-017-9441-4

Genevay, S., & Atlas, S. J. (2016). Lumbar spinal stenosis. Best practice & research. Clinical

rheumatology, 24(2), 253–265. https://doi.org/10.1016/j.berh.2009.11.001

MedlinePlus, December 7, 2020. Ankylosing Spondylitis. Retrieved from

https://medlineplus.gov/ankylosingspondylitis.html

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?

 

Respond to this

#2

Assessing Musculoskeletal Pain

 

Musculoskeletal pain primarily affects an individual’s quality of life through aspects such as sleep deprivation, fatigue, depression, as well as an activity together with participation restrictions. The set effect is also impacted by contextual facets that are also inclusive of comorbidity, arthritis coping efficiency, as well as access to care (Hawker, 2017). This then implies that musculoskeletal (MSK) pain evaluation necessitates set bio-psychosocial perspectives that encompass pain alongside baseline impacts combined with contextual facets.

 

Nerve roots that may be associated with back pain exhibit a set multifaceted, heterogeneous state whereby both the nociceptive alongside neuropathic pain mechanisms may be entailed. The pain is due to activation of the set nociceptors innervating ligaments, joints, muscles, fascia combined with tendons. This is due to the reaction to tissue injury or even inflammation combined with biomechanical stress. The neuropathic pain originates from injury or even illness that impacts the nerve roots innervating the spine together with the spine as well as the lower limbs, as well as pathological invasive innervation within the damaged lumbar discs (Baron et al., 2016).

 

Physical assessment can be undertaken by centralization (change of pain along the far end of the whole-length body region) of symptoms within physical assessments. (A positive test applied in ruling diagnosis). Physical assessment can also be done on the facet joint per centralization and lack of relief from recumbency. The other test is on the sacroiliac joint through centralization (Peterson et al., 2017). The next test is disc herniation together with root involvement whereby the dermatological distribution that mirrors neurological results, enhances the set specificity of the outcomes. Other tests would include spondylolisthesis, fracture, myofascial pain, peripheral nerve, and central sensitization.

 

Other symptoms that can be explored for the lower back pain include pain exhibiting dullness or is achy in nature within the lower back, stinging combined with burning pain from the lower back to the lower thigh back, muscle spasms combined with tightness within the lower back, prolonged pain while standing, as well as problems when standing straight or even walking (Allegri et al., 2016).

 

A differential diagnosis for acute lower back pain includes tailbone pain as a result of pain alongside the bony structure within the lower spine (Mayo Clinic, 2019). Another differential diagnosis is lumbar compression fracture due to the collapsing of the bony block or even the vertebral structure that causes acute pain, deformity as well as weight loss (Genev et al., 2017). Another differential diagnosis is psoriatic arthritis that depicts a state exhibiting red patches of skin alongside silvery scales that causes pain within joints (Mayo Clinic, 2019).

You are required to include at least two evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.

 

           

 

 

 

 

 

 

 

 

 

 

 

 

 

References

 

Allegri, M., Montella, S., & Slici, F. (2016). Mechanisms of low back pain: a guide for diagnosis and therapy. F1000 Research. https://doi.org/10.12688/f1000research.8105.1

 

Baron, R., Binder, A., Attal, N., Casale, R., Dickenson, A. H., & Treede, R.-D. (2016). Neuropathic low back pain in clinical practice. European Journal of Pain20(6), 861–873. https://doi.org/ 10.1002/ejp.838

 

Genev, I. K., Tobin, M. K., & Zaidi, S. P. (2017). Spinal Compression Fracture Management: A Review of Current Treatment Strategies and Possible Future Avenues. Global Spine Journal7(1). https://doi.org/https://doi.org/10.1055/s-0036-1583288

 

Hawker, G. A. (2017). The assessment of musculoskeletal pain. Clinical and Experimental Rheumatology 35(107), 8–12.

 

Mayo Clinic. (2019, April 20). How to relieve tailbone pain. Mayo Clinic. https://www.mayoclinic.org/tailbone-pain/expert-answers/faq-20058211#:~:text=Tailbone%20pain%20%E2%80%94%20pain%20that%20occurs,joint%20changes%2C%20or%20vaginal%20childbirth.

 

Mayo Clinic. (2019, September 21). Psoriatic arthritis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/psoriatic-arthritis/symptoms-causes/syc-20354076#:~:text=Psoriatic%20arthritis%20is%20a%20form,begin%20before%20skin%20patches%20appear.

 

Peterson, T., Laslett, M., & Juhl, C. (2017). Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews. BMC Musculoskeletal Disorders18(188). https://doi.org/https://doi.org/10.1186/s12891-017-1549-6

 

 

 

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