CC Lower back pain for the last month.

Response 1

 

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CC Lower back pain for the last month.

HPI: A 42-year-old Caucasian male experiencing lower back pain, with a quick onset lasting over the last month.  Pain is dull +6/10 and radiates down left leg.  Leaning forward makes it worse while standing straight relieves the pain, denies any other symptoms.

Current Medications: MVI daily, Metformin 500mg BID, Tylenol 1g TID PRN.

Allergies: NKDA

PMHx: Prediabetes – diagnosed 2020

Soc Hx: Pt works night security for local shipping company, HS grad, lives with wife and 1 adult child in single family home.  Retired military with adequate health insurance and coverage, poor dietician stating he’s already got the “sugars”, why stop now?  Last physical is unknown and reports only going to the Dr., when it is needed.  Coaches HS basketball team and active member of his church with strong support system.  No known exposure to pathogens in work or home setting.

Fam Hx: Father – Diagnosed with heart disease/CABG age 45 (living age 80), Brother – Deceased /Myocardial Infarction age 47

ROS:

GENERAL:  Denies tiredness/fatigue/malaise, low grade fever since last night.  Stable weight, no chills or night sweats, no recent infections.

HEENT:  No headaches, wears corrective lens for distance, no visual disturbances.  Denies any ear pain, hearing loss or discharge.  Sense of smell intact, no seasonal allergies, denies any taste changes or problems swallowing.  Good dentition, unknown last dental exam.

SKIN:  Denies any rash, open sores or itching.

CARDIOVASCULAR:  Denies chest pain, SOB, palpitations or any abnormal heart rate.  Strong family history of cardiac problems.

RESPIRATORY:  No SOB, orthopnea, cough, or difficulty breathing

GASTROINTESTINAL:  No GERD, no abdominal pain, no diet change, consistent BMs, no nausea/diarrhea

GENITOURINARY:  No difficulty starting or stopping flow, no dysuria, incontinence, or need for nocturnal micturition.  Monogamous relationship with wife of 20 years, no hx of STD’s.

NEUROLOGICAL:  Denies any issues with gait, no seizures, no recent falls with or without loss of consciousness,.

MUSCULOSKELETAL:  Pain in lumbar region radiating down left leg.

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.

O.

Physical exam:

Vital signs: T99.9, R18, HR 67, BP 142/78, SPO2 99%RA

General: Clean, well-groomed, no acute distress, Age-appropriate mentation and physical development, well nourished, well developed, Normal affect, good eye contact, standing next to table.

HEENT: Atraumatic, no drainage noted, swallows without difficulty, Face symmetrical, extraocular movements equal, auricles with no lesions or discharge, positive cough and gag reflex, good oral hygiene.

Chest/Lungs: Regular, bilateral and equal unlabored breathing.  Clear breath sounds throughout R&L lobe, last CXR June 2019

Heart/Peripheral Vascular: S1 & S2 noted, no extra heart sounds, NSR, good pulse and capillary refill all extremities, zero edema, color normal for patient

Musculoskeletal: Moves all extremities equally strong and spontaneously, +5/5 muscle strength all 4 extremities.

Neurological: Good sensation in lower extremities.

 

Diagnostic tests

1.         Laboratory studies – Pts with acute LBP /not required, however if suspected infection or malignancy ESR and C-Reactive protein (Deyo & Diehl, 2018)

2.         Imaging studies – without associated symptoms, use of imaging is not associated with improved outcomes (Chou, Fu, Carrino, & Deyo, 2009).

3.         History – Important to consider what factors have brough on the pain.

4.         Physical tests.

a.         Inspection of posterior- check for excessive curvature i.e., kyphosis or scoliosis.

b.         Movement – Evaluation of ROM by bending forward/backward/left/right at the waist, Hip ROM,

c.         Palpitation – Isolate pain either from spinal region (vertebra) or para-spinal region suggesting paraspinal muscle strain

d.         Neuro exam – Straight leg raising test to check for “nerve root irritation or lumbar disk herniation” (Ball, Dains, Flynn, Solomon, & Stewart, 2018).  Tripod sign to check for meningeal irritation. Additionally noting the sensation or lack of in the lower extremities.

e.         Reflexes – Check for nerve damage

Differential diagnosis

 

1.         Radiculopathy – High suspicion for pain that starts in the lower back and follows down left leg and increased pain while leaning forward, further suspect straight leg test to be positive along with tripod sign.

2.         Spinal stenosis – Based upon patients age, and presentation of pain shooting down leg.

3.         Vertebral compression fracture – pain that is worse with flexion and focused spinal tenderness, judging from pt’s hx of coaching basketball and if patient were to indorse an acute injury.

4.         Lumbar strain / sprain – General diffuse back pain that increases with movement but decreases with rest, uncommon for pain to travel to extremities.

5.         Metastatic cancer – by location can be related to multiple symptoms, would need history with associated findings such as weight loss, fatigue, night sweat and no relief with rest to reference.

 

 

 

Response 2

 

 

J.M. 15-years-old, Male, Caucasian

S.

CC Occasional clicking in one or both knees and a catching sensation under the patella

HPI: 15-year-old Caucasian male comes to the clinic with complaints of a clicking-sound when he moves his knee, along with a catching sensation behind his patella.

Location: Knees (bilaterally)

Onset: 1 month ago

Character: Clicking sound during flexion and extension.

Associated signs and symptoms: Catching sensation behind his patella

Timing: Intermittent occurrence, 3-5 times a day.

Exacerbating/ relieving factors: Clicking is worse after playing baseball and goes away after rest.

Severity: 0/10

Current Medications: Multivitamin, 1 tablet PO qday.

Allergies: Denies allergies to medications, food, or latex.

PMHx: Tdap (2020). Seasonal influenza (2022). Covid-19 (Prizer-2021) – Surgical History – Tonsillectomy (2010). Soc Hx: Attends Abington Junior High School and has a B-average. Patient plays baseball for the school and in the neighborhood. Denies use of tobacco products, alcohol, or illicit drugs. Patient has a part time job at McDonalds. Patient denies being sexually active.

Fam Hx:

· Mother (age 41) – Diabetes (type II)

· Father (age 40) – Hypothyroidism

· Sister (age 12) – No medical history

· Maternal grandmother (deceased 72 – Breast Cancer) – Hypertension, Diabetes (type II)

· Maternal grandfather (age 75) – Hypertension, Hyperlipidemia

· Paternal grandmother (age 70) – Bilateral knee replacement (2020)

· Paternal grandfather (age 74) – Hypertension, Hypothyroidism, Hyperlipidemia

ROS

GENERAL: Patient denies unintentional weight loss, weakness, or fatigue.

HEENT: Patient denies difficulty with vision. Patient also denies any recent hearing loss, difficulty swallowing, or runny nose.

SKIN:  Patient denies any rashes, redness, or bruising.

CARDIOVASCULAR:  Patient denies chest pain, edema, or shortness of breath upon exertion

RESPIRATORY:  Patient denies difficulty breathing, cough, or congestion.

GASTROINTESTINAL:  Patient reports normal bowel movements, and denies abdominal pain, nausea, and vomiting.

GENITOURINARY:  Patient denies difficulty urinating or

NEUROLOGICAL:  Patient denies headache, dizziness, or numbness in his extremities.

MUSCULOSKELETAL:  Patient endorses an intermittent clicking in both knees, as well as a catching sensation behind his patella.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes.

PSYCHIATRIC:  Patient denies thoughts of harming himself or other people. Patient reports being happy with his life.

ENDOCRINOLOGIC:  Patient denies polyuria, polydipsia, or polyphagia. Patient denies cold intolerance.

ALLERGIES:  Patient denies allergies.

O.

Physical exam:

GENERAL: Patient is dressed appropriately and appears to be practicing proper hygiene. He is attentive during our conversation and responds appropriately.

HEENT: Sclera and conjunctiva normal. Pupils are equal and reactive. No visual drainage from either the nose or the ears. Patient’s throat is pink with no signs of infection.

SKIN:  No bruising or rashes noted. A 3 cm abrasion is present on the patient’s left arm as a result of bumping into a desk at school. Good skin turgor.

CARDIOVASCULAR:  S1 & S2 auscultated with no adventitious heart sounds. No bruit or thrills noted in the carotid arteries. Pulses are +2 in the upper and lower extremities.

RESPIRATORY:  Lung sounds are equal and clear bilaterally. Symmetrical chest and diaphragmatic movement noted.

GASTROINTESTINAL:  Bowel sounds present x 4. Abdomen soft and nontender. Unable to palpate the liver or spleen.

GENITOURINARY:  Genitals intact. No signs of hernia.

NEUROLOGICAL:  Patient is Alert and Oriented x 4, equal strength, movement and sensation in all extremities.

MUSCULOSKELETAL:  Full ROM in all extremities. “Clicking-sound” noted when performing flexion and extension in the left leg.

HEMATOLOGIC:  No visible signs of bruising. Mucus membranes are pink and moist.

LYMPHATICS:  No swollen lymph nodes detected.

Diagnostic results: Knee X-ray (AP and Lateral)

A .

· Damaged Cartilage – The catching sensation when moving the knee may be indicative of cartilage damage in the knee (Keeling, 2011).

· Iliotibial Band Syndrome – May cause intermittent knee crepitus and is seen often in athletes due to repeated use and impact on the lower extremities (Geisler, 2021).

· Patellar Tracking Disorder – If the patient’s patella is not tracking properly it may cause instability in the patellofemoral joint which would account for the catching sensation the patient is experiencing (Xue, et al., 2020)

· Osteoarthritis of the Knee – Unlikely in a patient of this age, but something that should be checked nonetheless due to the risk of further deterioration and loss of mobility.

· Air bubbles in Synovial Space – Normal occurrence which would account for the clicking sound but not the catching sensation

In determining the causes of the knee pain, what additional history do you need?

· History of trauma, prior surgical history, and lifestyle assessment (activity level).

What categories can you use to differentiate knee pain?

· Frequency of the knee pain, characteristics of the knee pain, and severity.

What are your specific differential diagnoses for knee pain?

· Cartilage damage, torn ligament, osteoarthritis.  

What physical examination will you perform?

· Visual inspect the patient’s knees for any signs of swelling

What anatomic structures are you assessing as part of the physical examination?

· Anterior Cruciate Ligament, Posterior Cruciate Ligament, Medial Meniscus, Lateral Meniscus, and Patella

What special maneuvers will you perform?

· Patella, McMurray Test, Drawer Test, Lachman Test

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