Lindsay Claggett Week 8 Discussion Post Back Pain COLLAPSE WEEK 8 DISCUSSION Focused SOAP note for a 42 year old male

Lindsay Claggett Week 8 Discussion Post: Back PainCOLLAPSE

WEEK 8 DISCUSSION: Focused SOAP note for a 42-year-old male who reports pain in his lower back for the past month that sometimes radiates to his left leg.

PATIENT NAME: S. F.                                                                 AGE: 42

SEX: Male

CHIEF CONCERN:

“I’ve been having left lower back and leg pain for about a month now that doesn’t seem to be getting better”

HISTORY OF PRESENT ILLNESS:

This is a 42-year-old Caucasian male who reports left-sided low back pain for the past month that radiates down the back of his left leg. He describes the pain as a deep aching and burning sensation and rates the pain a 5-6/10 at times. He states the leg pain is often worse than his back pain and reports frequent “tingling” sensations down his leg. He reports that the pain is worse at work when he is moving or bending and has caused him to leave work early a few times. He has been taking naproxen for his pain which “only helps some”, reducing his pain to around a 2-3/10.

PAST MEDICAL HISTORY:

1. Insomnia: diagnosed 8 years ago- controlled

SURGICAL HISTORY:

1. Tonsillectomy/adenoidectomy- age 3

2. ORIF right radius/ulna- age 16, sports injury

3. Wisdom teeth extraction- age 18

MEDICATIONS:

1. Trazodone 100 mg PO at bedtime- last dose yesterday evening at 1930

2. Naproxen 250 mg PO q6 hours for back pain- last dose this morning at 0700

ALLERGIES:

NKDA

HEALTH MAINTENANCE:

-Tdap vaccine- 6/2016

-flu vaccine- 11/2020

-last PCP visit- 11/2020

FAMILY HISTORY:

-father alive at 68, history of HTN, HLD

-mother alive at 66, history of anxiety/depression, migraines, RA

-sister alive at 39, no medical issues

-paternal grandfather deceased at 81 from pancreatic CA, history of HTN, HLD, DM

-paternal grandmother alive at 89, history of OA and dementia

-maternal grandfather deceased at 78, COPD, RA

-maternal grandmother alive at 85, history of depression, breast CA

-son alive at age 17, history of asthma

-daughter alive at age 14 with no medical issues

SOCIAL HISTORY:

Patient admits to smoking a pack of cigarettes a day for 20 years. He admits to drinking 6-8 beers every weekend. He reports drinking 3-4 cups of coffee every day. He denies illicit drug use. Patient eats a standard American diet and denies a current exercise regimen. Patient is a factory worker and reports moderate physical and mental stress levels but states he has a strong support system from family and friends and denies issues affording healthcare or medications.

REVIEW OF SYSTEMS:

GENERAL: Denies fever, fatigue, or recent weight changes.

CARDIOVASCULAR: Denies chest pain, palpitations, or peripheral edema.

RESPIRATORY: Denies dyspnea or cough.

GASTROINTESTINAL: Denies abdominal pain, nausea, vomiting, or changes in bowel habits.

GENITOURINARY: Denies urgency, frequency, hesitancy, dysuria, nocturia, hematuria, or flank pain.

MUSCULOSKELETAL: Reports occasional left lower extremity “heaviness” but denies noticeable weakness. Denies joint stiffness or swelling, limited ROM, gait changes or recent injury.

INTEGUMENTARY: Denies rashes, itching, lesions, skin changes, or excess bruising.

NEUROLOGICAL: Denies dizziness, headaches, or changes in memory, concentration, coordination, or strength.

PHYSICAL EXAM:

VITAL SIGNS: Ht: 180 cm Wt: 99.7 kg BMI: 30.8 T: 36.9°C BP: 138/88 P: 80 R: 18 O2 sat: 97% on RA

GENERAL: Patient is alert, oriented, and sitting on the exam table in no acute distress. He is cooperative with clear speech and answers questions appropriately. He appears well-nourished, well-groomed, and slightly older than stated age.

INTEGUMENTARY: Skin is warm and dry with good turgor. No lesions or bruising noted. Multiple healed tattoos noted to arms, chest, and back.

CARDIOVASCULAR: Chest symmetrical. Heart RRR. S1 and S2 audible with no extra sounds noted. No noted peripheral edema.

RESPIRATORY: Breath sounds clear to auscultation in all lung fields. Chest wall and expansion symmetrical with no increased effort of breathing.

GASTROINTESTINAL: Abdomen round and symmetrical. Bowel sounds normoactive in all quadrants. No dullness to percussion. Abdomen is soft with no guarding, tenderness, organomegaly, or masses noted on palpation.

MUSCULOSKELETAL: Full weight bearing with full ROM to all extremities. Upper and lower extremities symmetrical without swelling, redness, or deformities. Positive left straight leg-raise test/femoral stretch test at 45°

NEUROLOGICAL: Alert, oriented, and cooperative with appropriate mood and affect. Motor strength 5/5 to bilateral upper and lower extremities.

DIFFERENTIAL DIAGNOSES WITH SUPPORTING DIAGNOSTICS:

1. Sciatica

Sciatica is a common condition caused by nerve irritation, inflammation, pinching, or compression resulting in low back pain that radiates down one or both legs along the sciatic nerve. Typical symptoms are lumbar pain with unilateral radiating leg pain that is typically worse than back pain. The pain is usually referred to as sharp or aching and can be accompanied by numbness and paresthesia, and weakness in the affected leg (Jensen et al., 2019). Pain is often exacerbated by lumbar spinal flexion, twisting, bending, or coughing. Risk factors associated with sciatica include obesity, smoking, and certain occupations such as manual labor (Jensen et al., 2019). Diagnosis of sciatica is typically based on subjective data and physical exam findings along with various tests such as the straight-leg raise (SLR) or femoral stretch test and the slump test. Imaging, such as MRI and CT scans, is not typically advised unless pain worsens, lasts longer than 12 weeks, or leads to progressive neurological and musculoskeletal deficits (Jensen et al., 2019).

2. Piriformis Syndrome

Piriformis syndrome is a condition that occurs when the piriformis muscle in the buttocks becomes tight, inflamed, or spasms, irritating or compressing the sciatic nerve. Pain is typically described as aching, burning, or sharp, shooting pain in the low back and gluteus that radiates down the back of the leg (Roy, 2014). Numbness and tingling in the affected extremity may also be present. Piriformis syndrome is more common among women and is associated with prolonged sitting or overuse, such as running or cycling (Roy, 2014). This condition closely mimics and is frequently misdiagnosed as sciatica, and no definitive testing exists (Roy, 2014). Diagnosis of piriformis syndrome is typically based on patient history and physical exam and may include techniques like applying manual pressure around the sciatic nerve or performing stretch tests, such as Freiberg, Beatty, or FAIR maneuvers, that reproduce the patient’s symptoms.

3. Herniated Lumbar Disc

A herniated lumbar disc is among the most common causes of low back pain, occurring when the soft inner nucleus of the spinal disc protrudes through the outer annulus and irritates or compresses nearby nerves. Common symptoms of a herniated lumbar disc include constant or intermittent low back or buttock pain that radiates down the leg, lower extremity weakness, numbness, or tingling, and increased pain with strain, like coughing or sneezing, or when seated (Amin et al., 2017). While disc herniation can have a genetic component, it is typically the result of age-related degenerative changes or spinal overloading, which can occur from obesity, excess physical demands and overuse, or even a sedentary lifestyle (Amin et al., 2017). Diagnostics like muscle, nerve, and SLR testing along with history and physical can help diagnose a herniated lumbar disc, but MRI remains the gold standard for confirming suspected disc herniation (Amin et al., 2017).  

4. Lumbar Spinal Stenosis

Lumbar spinal stenosis (LSS) can be congenital or acquired and is caused by degeneration and overgrowth of bone and soft tissue in the lower spine that can lead to nerve irritation and compression and associated symptoms. Common symptoms of LSS include low back and buttock pain that radiates down the leg, typically bilaterally, which worsens with prolonged standing, walking, or lumbar extension (Andaloro, 2019). Pain is usually described as sharp, burning, or aching and may be accompanied by numbness or tingling. Risk factors for LSS include obesity, tobacco use, repeated occupational stress or overuse, and most importantly, age, with symptoms progression worsening with time (Andaloro, 2019). Diagnosis is made with a combination of clinical findings and radiographic imaging, with MRI being the gold standard (Andaloro, 2019).

5. Sacroiliitis

Sacroiliitis, or inflammation of the sacroiliac joint, can result from a variety of degenerative and non-degenerative conditions such as injury, pregnancy, osteoarthritis, infections, or rheumatic inflammatory conditions and is considered the hallmark of axial spondylarthritis (Slobodin et al., 2018). Sacroiliitis usually manifests as gradual low-back, buttock, and hip pain that may be bilateral or unilateral and worse at night and upon waking. Along with history and physical, diagnosis can be made through a combination of techniques to reproduce pain, such as the FABERE test, pelvic rock test, or Gaenslen maneuver, radiographic imaging, like x-ray, CT, or MRI, and laboratory testing to assess for inflammatory or malignant processes (Slobodin et al., 2018).

REFERENCES

Amin, R. M., Andrade, N. S., & Neuman, B. J. (2017). Lumbar disc herniation. Current Reviews in Musculoskeletal Medicine, 10(4), 507–516. https://doi.org/10.1007/s12178-017-9441-4

Andaloro, A. (2019). Lumbar spinal stenosis. Journal of American Academy of Physician Assistants, 32(8), 49-50. http://dx.doi.org/10.1097/01.JAA.0000569788.21941.ca

Jensen, R. K., Kongsted, A., Kjaer, P., & Koes, B. (2019). Diagnosis and treatment of sciatica. BMJ, 367, l6273. http://dx.doi.org/10.1136/bmj.l6273

Roy, B. (2014). Piriformis syndrome. ACSM’s Health & Fitness Journal, 18(4), 3-4. http://dx.doi.org/10.1249/FIT.0000000000000055

Slobodin, G., Hussein, H., Rosner, I., & Eshed, I. (2018). Sacroiliitis – early diagnosis is key. Journal of Inflammation Research, 11, 339–344. https://doi.org/10.2147/JIR.S149494

Adebukola Aladesanmi week 8 initial postCOLLAPSE

Patient Information

Patient Initials: Mr. X

Age: 42 years

Gender: Male.

Race/Ethnicity: African American.

Subjective:

CC: “Pain in my lower back for the past one month. The pain sometimes radiates to my left leg.”

HPI: The patient is a 42 years African American male presenting with dull lower back pain for the last one month. The pain started after he worked in his garden. It radiates to his left leg after prolonged sitting and it has significantly affected his productivity at work. He rates the pain as an 8/10 and he has taken paracetamol 1000mg twice daily for the past two weeks. Although it provides some pain relief, the pain persists thereafter.

Current Medications: Nifedipine 20 mg PO daily, Lipitor 20 mg PO daily.

Allergies: He has no known food or drug allergies.

PMHx: He was diagnosed with hypertension ten years ago and is on medication for hyperlipidemia. His immunization status is up to date- TDap 2014 and Influenza October 1, 2016.

Soc Hx: He smokes a maximum of 6 cigarettes a day and denies alcohol or any illicit drug use. He is a staunch catholic who attends services every Sunday. He does not exercise regularly.

Fam Hx: His mother died three years ago from diabetic complications. His father is hypertensive and has currently been diagnosed with diabetes at 75 years old. He also suffers from osteoarthritis.

ROS:

General: The patient denies lack of energy, fevers, chills, night sweats, and weight changes.

Skin: Denies persistent rash, itching, new skin lesion, hair loss, or increase.

HEENT: Denies difficulty with hearing, sinus pain/pressure, congestion, runny nose, post-nasal drip, ringing in ears, difficulty swallowing, mouth sores, loose teeth, ear pain, nosebleeds, sore throat, facial pain or numbness, neck pain/stiffness.

Cardiovascular: Denies chest pain, irregular or rapid heartbeat.

Respiratory: Denies shortness of breath, cough, wheezing, or sputum production.

GI: Denies heartburn, constipation, nausea, vomiting, diarrhea, abdominal pain, difficulty swallowing, blood in stools, unexplained change in bowel habits, or incontinence.

GU: Denies painful urination, frequent urination, urgency, urine retention, changes in penial discharge, impotence.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

Musculoskeletal: Denies joint pains, muscle pain/tenderness, neck pain, thigh or calf cramps.

Neurologic: Denies frequent headaches, double vision, weakness, decreased sensation to extremities, denies numbness or tingling of extremities, denies numbness, or tingling of extremities, imbalance, unsteady gait, dizziness, tremor, loss of consciousness, uncontrolled motions, episodes of visual loss, bowel or bladder incontinence.

Psychiatric: Denies insomnia, depression, recurrent bad thoughts, mood swings, hallucinations, compulsions.

Endocrine: Denies intolerance to heat or cold, menstrual irregularities, frequent hunger/urination/thirst.

Hematological: Denies bleeding tendencies such as nose bleeds or gum bleeding, easy bruising.

Objective

Vital Signs: Bp: 140/70, HR: 80 beats/min, 20 RR, HT: 5’5’’, WT: 176.37 lbs.

Physical Examination

The patient has no back tenderness, positive Lasegue sign (straight leg test), absent ankle reflex, unremarkable strength, and sensation, intact bilateral hip motion. 

Laboratory Findings

Magnetic resonance imaging is the most accurate assessment for the lumbar spine area (Wassenaar et al., 2017). It reveals the exact position for herniation and the affected nerves. The patient’s result reveals a lumbar herniation at the level of L5-S1. An Electromyography confirms the compression of the sciatic nerve secondary to the herniation. However, there is no evidence for any arthritic condition impact on the nerves.

Assessment

A herniated lumbar disk is the most probable diagnosis for the patient. It is also referred to as a slipped or ruptured disc that can occur anywhere along the spine but it is common on the lower back or neck (Amin et al., 2017). Spinal discs separate each vertebra as a protective mechanism from shock. They are also responsible for movements like twisting and bending. Their absence would mean that the discs will grind on each other since there is no protection from trauma or body weight. Pain occurs when the outer part of the outer disc presses against the nerves that run along the spinal column and could explain the patient’s lower back pain. The pain started after working in the garden. It is a strenuous physical activity suspicious for traumatizing the patient’s lumbar disks. Moreover, he is overweight with a BMI of 29.3 which increases his possibility for a herniated disc. Nicotine is also responsible for intervertebral disc generation through cell damage in the annulus and nucleus (Amin et al., 2017). The patient is a smoker, a habit that increases his risk for lumbar disc complications.

Sciatica is a differential diagnosis for the patient. The sciatic nerve originates from the spinal column and runs through the hips and buttocks before branching down to every leg (Amin et al., 2017). It is a possibility because the patient’s pain originates from the back and radiates to his left leg. A possible explanation is that a herniated disc impinges on the nerves at the level of L5-S1. Evidence shows that nerve impingement is aggravated by actions like coughing, sneezing, or prolonged sitting (Amin et al., 2017). It is consistent with the patient’s aggravated symptoms with prolonged sitting and a positive straight leg test where pain spread down his leg. The dull pain is also consistent with nerve impingement or radiculopathy.

Spinal stenosis is a possible diagnosis for the patient. It is a narrowing of the spinal canal in the lower part of the spine resulting in pressure on the spinal cord or the nerves that go from the spine to the muscles (Genevay & Atlas, 2017). Although it can occur at any part of the spine, it is common at the lower part- the lumbar vertebrae. Common causes include injury to the spine, bone diseases, and rheumatoid arthritis (Genevay & Atlas, 2017). The patient is experiencing lower back pain which makes it a possible diagnosis. Evidence shows that RA follows a genetic cause due to variations in the human leukocyte antigen HLA- DRB1 gene (Genevay & Atlas, 2017). The past family history of rheumatoid arthritis (RA) is a possible explanation for the possibility of spinal stenosis for the patient. Moreover, the beginning of the symptoms after working in the garden also rises suspicion of spinal injury

References

Amin, R. M., Andrade, N. S., & Neuman, B. J. (2017). Lumbar disc herniation. Current reviews in musculoskeletal medicine,10(4),507-516. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685963/

Genevay, S., & Atlas, S. J. (2017). Lumbar spinal stenosis. Best practice & research Clinical rheumatology, 24(2), 253-265. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841052/

Wassenaar, M., van Rijn, R. M., van Tulder, M. W., Verhagen, A. P., van der Windt, D. A., Koes, B. W., & Ostelo, R. W. (2018). Magnetic resonance imaging for diagnosing lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. European spine journal, 21(2), 220-227.

pls respond with 3 resources for each discussion.