Case 1: 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?
M.S. Age 42 Caucasian Male
CC: “Lower Back Pain”
HPI: The patient is a 42-year-old white male who developed lower back pain for 1 month. He states the pain radiates to his left leg. His lower back pain is increased with sitting for long periods of time, states the pain gets better when stands and with some Tylenol. Denies any fever, chills, and sweating.
Current Medications: Tylenol 200 mg two every 4 to 6 hours as needed for pain.
Allergies: No known drug, food, or environmental allergies.
PMHx: None Up to date on all immunizations, received flu shot this year. Last tetanus shot 1 years ago.
Soc Hx: M.S. is a retired plumber who lives alone. He enjoys activity such as walking, bike riding and camping outdoors. Nonsmoker, social drinker 3-4 beers on the weekends, denies illegal drug use.
Personal/Social History: Patient denies ever smoking cigarette. Denies any recreational drug use.
Fam Hx: Mother alive, age 72-years-old, breast cancer at age 52 in remission. Father died at age 70 (2yrs ago) – history of CAD, MI age 70 died. Maternal grandmother: Hypertension, breast cancer. Maternal grandfather: Hypertension, BPH, GERD, atrial fibrillation, hyperlipidemia, CHF, AICD. Paternal grandmother: Unknown history
Paternal grandfather: Hypertension, CKD, GERD, BPH, COPD, asthma.
GENERAL: No weight loss. Complaint of lower back pain. No complaint of fever, chills, weakness, fatigue, constipation, bladder, or bowel incontinent.
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 or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No Complaint of sob, no cough.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or bowel incontinent, no rectal pain or bleeding
GENITOURINARY: No difficulty with urination, no urinary leakage or incontinence.
NEUROLOGICAL: No headache, no dizziness, no syncope, no paralysis, no ataxia, no numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: complaints of lower back pain radiate to back of right leg. Pain 8/10, sometimes increase pain when turning in bed, walks with limp when having pain. Patient reports a lower back for one-month, intermittent pain when ambulating that shoots down the right, lateral thigh, down to the knee, and no numbness of leg. The patient states his pain is relieved somewhat with his OTC Tylenol. Patient denies any swelling, redness, or heat at any of the joint sites.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes in the groin. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No complaints of fever, chills, and sweating.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
VS: BP 140/76; P 82; R 19; T 97.7F; O2 SAT 99%; Wt. 200 lbs.; Ht 6’8”, pain 8/10 on scale of 0-10 at rest
General: 42-yr-old Patient presents as a well-developed, young adult Caucasian who appears his stated age. He is alert, oriented, and cooperative. The patient walks with slight limp,
HEENT: normocephalic head with normal distribution of hair. No facial tenderness to light sensation. Conjunctivae are pink with white sclera and without jaundice. PERLA, with pupils 3mm in size bilaterally. No exudates seen. Nasopharynx and pharynx without erythema, lesions, or exudates. Mucous membranes are moist. Upper and lower teeth in good condition and intact. The trachea is midline.
Neck: normal ROM, Supple with no JVD or bruits, there is no adenopathy. No swelling noted.
Chest/Lungs: Lungs are clear to auscultation anteriorly and posteriorly with equal symmetry of chest rise and fall. Resonance noted to percussion bilaterally. No wheezes, rhonchi or stridor.
Cardiovascular: RRR without murmur. Good S1, S2. Radial and pedal pulses +2 bilaterally. No abdominal, carotid, or femoral bruits. No JVD.
Peripheral vascular: No edema of extremities. 2+ palpable radial, posterior tibial, and dorsalis pedis pulses. Normal distribution of hair on lower extremities. Normal color. Capillary refill less than 3 seconds. No cyanosis or clubbing present.
Abdomen: Flat, soft NABS x4. non-tender, no inguinal nodes noted.
Musculoskeletal: Symmetrical development of upper and lower extremity. No erythema or deformities of joints. Palpate pain noted at the right lower lumbar region. Pain to lower back when leg is extended while thigh if flexed when lying flat. Limited ROM of right leg with pain at 40 degrees when lifting. ROM limited to forward bending 10 inches from the floor. Pain to right buttock area and right posterior thigh with palpation. Minimal flexion of the right knee due to pain. No crepitus or stiffness to palpitation of joints. Other joints unremarkable.
Neurological: CN II-XII intact. DTRs 2+ lower extremity intact. Sensory neurology intact to light touch and patient able to toe and heel walk. Normal gait with ambulation and limping noted.
Skin: Warm and dry to touch. No ecchymosis or edema. No noted rashes, open wounds, or lesions. Hair is evenly distributed over scalp.
a. Walk across the room to examine abnormalities in patient gait (pattern of walking)
b. Hip flexion and knee hyperextension up to 30 degrees. Bend or flex parts of your spine to assess spinal range of motion example bend forward)
c. Simply stand to identify any problems with balance, posture and/ spinal alignment
d. The femoral stretch test is used to detect inflammation of the nerve root at the L1, L2, L3 and L4
e. CBC: used to confirm the diagnosis of infection.
f. Urinalysis to check for UTI.
g. XR lumbar spine
h. Plain-film X-ray provides 2 view of motion and evidence of trauma.
i. CT scanning: Detect abnormal tissue and the state of the patient’s spine.
j. MRI Lumbar spine: used to generate detailed images or slices of the spinal anatomy. MRI also can reveal the structure of soft tissues, such as the discs, spinal cord, and nerves. (Dains, J. E., Baumann, L. C., & Scheibel, P., 2016).
1. Lumbosacral Herniated Disc
2. Cauda Equina
3. Musculoskeletal Lumbar Strain
4. Acute Pyelonephritis,
5. Lumbar spinal stenosis
Lumbosacral Herniated Disc is the most appropriate diagnosis. The authors Kim et al., 2018, stated that “one person from eight suffers from degenerative disc disease, as well as from various joint diseases (arthrosis, arthritis, sciatica), the pain being in the medial or inferior part of the spine. At first, it is manifested as a slight redness, then pain occurs when walking or bending, and then gradually radiating to the leg, which can affect the individual life” (Kim et al.,2018). And my patient is exhibiting these symptoms.
Lumbosacral Herniated Disc (Sciatica): According to Ball et al., 2015 Herniated disc disease usually caused by degenerative changes in the disc. The most common sources of back pain are abnormally changed discs, facet and sacroiliac joints, and muscles; however, it is often difficult to determine the main source of pain. The nerve root generally involves occurs at L4, L5 and S1 nerve roots. This patient is at greater risk because of his age group and may involve trauma because this patient occupation as a plumber.
According to Koes, Van-Tulder and Peul 2007 “other symptoms that need to be explored are unilateral leg pain greater than low back pain, Pain radiating to foot or toes, numbness and paranesthesia in the same distribution, straight leg raising test induces more leg pain, localized neurology changes that involves L4, L5 and S1 that which is to limit one nerve root” (Koes., van Tulder., & Peul, 2007).
Cauda Equina: According to Dains, Baumann and Scheibel 2016, “Cauda Equina compression of S1 nerve root produce continuous lower back pain with saddle distribution of anesthesia. The patient will present with symptom include lower back pain, unilateral or bilateral sciatica nerve pain, bowel, and bladder disturbances generally present with BB incontinence, lower extremity motor weakness with limping, sensory losses or deficits in the lower extremity and reduced or absent lower extremity reflexes” (Dains, J. Baumann, L. & Scheibel, P. 2016). I choose it because my patient is presenting with some of the symptoms.
Musculoskeletal Lumbar Strain: Lumbar strain is based on history and clinical findings. A complete history may suggest the cause of acute lower back pain based on the type of injury the patient sustained (Lupu., A.,2017). If the patient present with no history of trauma or no history of strenuous physical activities, then the likely diagnosis of Lumbar strain is evident. According to Dains, Baumann and Scheibel 2016 “muscles in the back can become inflamed from over usage of muscles and ligaments. Patient report that rest will alleviate pain and with treatment of heat or cold therapy” (Dains, J. E., Baumann, L. C., & Scheibel, P., 2016).
Acute Pyelonephritis: The range of acute pyelonephritis is wide, from a mild illness to sepsis. According to Dains, Baumann and Scheibel 2016, “patients may appear very ill and diaphoretic with symptoms of nausea, vomiting, headache, and back or flank pain” (Dains, J. E., Baumann, L. C., & Scheibel, P., 2016). To diagnose acute pyelonephritis, the practitioner must rely on evidence of UTI from urinalysis or culture, along with signs and symptoms suggesting upper UTI (fever, chills, flank pain, nausea, vomiting, costovertebral angle tenderness). Symptoms that are suggestive of cystitis (dysuria, urinary bladder frequency and urgency, and suprapubic pain) also may be present.
Lumbar spinal stenosis – Lumbar spinal stenosis (LSS) is a disease in which degenerated discs, ligamentum flavum, facet joints, while aging, lead to a narrowing of the space around the neurovascular structures of the spine (Fishchenko et al., 2018). Symptoms may be due to inflammation or compression of the nerve and include pain and weakness or numbness in the legs. There is no ‘gold standard’ for diagnosis of LSS; the diagnosis is based on a combination of factors including history, physical examination, and imaging studies. Assessment should focus on leg or buttock pain while walking, flex forward to relieve symptoms, feel relief when using a shopping cart or a bicycle, motor or sensory disturbance while walking, pulses in the foot present and symmetric, and lower extremity weakness (Chagnas et al., 2019). Imagining can be used to determine if there is any inflammation, and when surgery is becoming imminent.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Koes, B. W., van Tulder, M. W., & Peul, W. C. (2007). Diagnosis and treatment of sciatica. BMJ: British Medical Journal, 334(7607), 1313–1317. http://doi.org/10.1136/bmj.39223.428495.BE
Jung-Ha Kim, Rogier M. van Rijn, Maurits W. van Tulder, Bart W. Koes, Michiel R. de Boer, Abida Z. Ginai, Arianne P. Verhagen. (2018). Diagnostic accuracy of diagnostic imaging for lumbar disc herniation in adults with low back pain or sciatica is unknown, a systematic review. Chiropractic & Manual Therapies, Vol 26, Iss 1, Pp 1-14 (2018), (1), 1. https://doi-org.ezp.waldenulibrary.org/10.1186/s12998-018-0207-x
Lupu., A., (2017). Diagnosis and treatment difficulties in the case of a patient with Chronic Low Back Pain. Balneo Research Journal, Vol 8, Iss 4, Pp 248-251 (2017), (4), 248. https://doi-org.ezp.waldenulibrary.org/10.12680/balneo.2017.160
NURS 6512: Advanced Health Assessment and Diagnostic Reasoning INITIAL POST
Case Study #3
Patient Initials: _SC__ Age: __15___ Gender: _M__
Chief Complaint (CC): A dull pain in both knees with occasional clicking in one or both knees and the sensation of the patella catching.
History of Present Illness (HPI): SC is a 15-year-old male who reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. He states that the pain has been on and off for the last four months and initially only present after intense activity but has gotten worse since starting track this summer and seems to be present more often than before. The patient states that the clicking comes and goes and isn’t always present in both knees at the same time. The catching sensation under the patella is more pronounced since he started doing the long jump in track. The patient states that he is able to bear weight as the pain is a dull ache. Icing his knees after sports and taking ibuprofen help reduce the pain and swelling but both occur more frequently now making it difficult to participate in sports. The patient feels that maybe he is over doing it with all of the sports he participates in and is worried about not being able to pay soccer if it continues to get worse. The patient rates the pain 7/10 after extreme activity.
Ibuprofen 200 mg oral tab, two tabs every 6 hours as needed for pain.
Allergies: No known drug, food, or environmental allergies.
Past Medical History (PMH): None
Past Surgical History (PSH): None
Sexual/Reproductive History: Patient is not sexually active at this time.
Personal/Social History: Patient denies smoking, alcohol use, and illicit drug use. The patient is very active with sports playing soccer, basketball and track. He states that he tries to eats well particularly because of sports but doesn’t always make the best choices for snacks. He tries to avoid soda most of the time and does drink a lot of water.
Immunization History: Immunizations are up to date. Gets the flu vaccine routinely every year.
Significant Family History:Paternal grandmother has hypertension. Father has borderline hypertension. Maternal grandmother has type II diabetes. Lifestyle: SC is a freshman in high school who lives with both of his parents and 2 younger siblings, a brother and sister. SC plays soccer, basketball and participates in track for high school. SC also plays club soccer playing most of the year. SC is a good student who is very athletic and enjoys being active. He also participates in winter sports and skis almost every weekend during the winter months. He only works part-time during the summers due to his commitment to school and sports.
Review of Systems:
General: No recent weight gain or loss of significance. Patient denies fatigue, fever, or chills.
HEENT: No headaches or dizziness. No changes in vision. He does not wear glasses and his last eye exam was just under a year ago. Denies eye drainage, pain, or double vision. No changes in hearing. Has had no recent ear infections, tinnitus or ringing in the ears. Denies sinus infections, congestion, and epistaxis. He reports his sense of small is intact. Last dental exam 3 weeks ago for regular cleaning. Denies bleeding gums or toothache. Denies dysphagia or throat pain. Neck: No history of trauma, denies recent injury or pain. He denies neck stiffness.
Breasts: Denies any breast changes. Denies of history rashes. Denies history of masses or pain.
Respiratory: Denies cough, hemoptysis, and sputum production. Patient denies any shortness of breath with resting or with exertion. Patient reports no pain with inspiration or expiration.
Cardiovascular/Peripheral Vascular: No history of murmur or chest palpitations. No edema or claudication. Denies chest pain. No history of arrhythmias. Last bowel movement was this morning. Denies rectal pain or bleeding. Denies changes in bowel habits. Denies history of dyspepsia.
Genitourinary: Denies changes in urinary pattern. No incontinence, no history of STDs or HPV, patient is heterosexual and not sexually active. Denies hematuria. Denies urgency, frequency, and dysuria.
Musculoskeletal: No limitation in range of motion for all limbs though patient reports difficulty moving knees after excessive strain from sports. No history of trauma or fractures. Patient reports dull pain in both knees. Patient states occasional swelling in knee joints after participating in sports. Patient reports clicking in one knee and sometimes both. Patient states that the pain is worse after participating in the long jump or running longer distances. Patient denies history or presence of misalignment of either knee.
Psychiatric: Denies suicidal or homicidal history. No mental health history. Denies anxiety and depression.
Neurological: No dizziness. No problems with coordination. Denies falls or seizures. Denies numbness or tingling. Denies changes in memory or thinking patterns.Skin: No history of skin cancer. Denies any new rashes or sores. Patient reports occasional plantar warts which he has treated with compound W. Denies eczema and psoriasis. Denies itching or swelling.
Hematologic: No bleeding disorders or history of blood transfusion. Denies excessive bruising.
Endocrine: Patient reports no endocrine symptoms.Denies polyuria, polydipsia. Patient denies no intolerance to heat or cold. Allergic/Immunologic: Denies environmental, food, or drug allergies. No known immune deficiencies.
Physical Exam: Vital signs: B/P 122/80; P 70 and regular; T 98.6; RR 16; O2 100% on room air; Wt: 122 lbs.; Ht: 5’7”; BMI 19.1
General: SC is a well-developed, well-nourished Caucasian teenage male who appears to be in no apparent distress.
HEENT: Head: Skull is normocephalic, atraumatic. No masses or lesions. Eyes: PERRLA, +direct and consensual pupil response. EOM intact, 20/20 vision bilaterally without correction. Fundoscopic exam normal, vessels intact, optic disc with clear margins. Ears: Bilateral external ears no lesions, masses, drainage or tenderness. Tympanic membranes intact, pearly gray, no bulging, no erythema, and landmarks appreciated bilaterally. Hearing intact bilaterally. Nose: No nasal flaring, no discharge, no obstruction, septum not deviated. Turbinates pink and moist. No polyps or lesions bilaterally. Nares patent with no edema or erythema. Throat: Oropharynx clear and mucosa moist. No erythema or exudate. Uvula midline, palate rises symmetrically.Mouth: No lesions, no thrush. Moist mucous membranes. Healthy dentition present. Tongue midline. Neck: Supple, non-tender. Full range of motion. Trachea midline. No masses. Thyroid and lymph nodes not palpable.
Chest/Lungs: Thorax non-tender with symmetric expansion. Respiration regular and unlabored, without cough. Tactile fremitus equal bilaterally and greater in upper lung fields. Breath sounds clear with adventitious sounds. All lung fields with resonant percussion tones.
Heart: Regular rate and rhythm; normal S1, S2; no murmurs, rubs, or gallops. Apical pulse not visible. Apical pulse barely palpable. JVP appears to be approximately less than 6 cm with HOB elevated to 45 degrees. No carotid bruits or JVD appreciated. Peripheral Vascular: Pulses 2+ bilateral pedal and 2+ radial bilaterally. No pedal edema. Popliteal pulses 2+ bilaterally.
Abdomen: Abdomen round, soft, and non-tender without rash, palpable mass or organomegaly. Active bowel sounds. Tympany over most quadrants with scattered areas of dullness noted upon percussion. No abdominal bruits.
Genital/Rectal: Adequate tone, no masses noted, eXternal genitalia intact.
Musculoskeletal: Normal passive and active ROM in upper and lower extremities. No focal joint inflammation or abnormalities appreciated in upper extremities. + tenderness to palpation at the inferior pole of the patella bilaterally. + Q angle greater than 10 degrees bilaterally. Clicking present with movement in right knee. Normal alignment of the knees bilaterally. All upper and lower extremity joints without effusions or erythema. Spine without tenderness and range of motion is full. Greater tenderness was noted in knees bilaterally when extended and quadriceps are relaxed. Normal muscle strength present against resistance.
Neurological: CN ll-Xll grossly intact. Awake, alert, and oriented to person, place and time. Patient can move all limbs on command and spontaneously.Skin: Warm, moist, and intact. Skin is pale. + edema right knee. No peripheral cyanosis. No clubbing. No rashes or bruises present.
Manual muscle testing: Manual muscle testing is an attempt to assess the maximum force a muscle can generate. In addition to standard orthopedic and neurologic assessments, applied kinesiology (AK) practitioners use MMT to identify what are believed to be immediate neurological responses to a variety of challenges and treatments (Conable, & Rosner, 2016). Testing shows flexion at the knee of 5/5 with pain, Knee extension with pain 5/5, Knee ER 5/5, Knee IR 5/5.
Musculoskeletal Tests: Ambulates with a limp, moderate discomfort with flexion and extension. Positive for swelling in both knees, slight warmth present. Positive McMurray’s and patella grind
X-ray: Many knee problems are better diagnosed by X-ray, and obtaining an X-ray as the first step is the usual course in diagnosing a knee condition. X-ray can determine soft tissue changes, bone quality, bone alignment, signs of early arthritis and trauma and fracture. Abnormalities such as bone growths, fractures or dislocation can be seen on the x-ray (Manaster, 2017)
MRI: In orthopedics, an MRI may be used to examine bones, joints, and soft tissues such as cartilage, muscles, and tendons for injuries or the presence of structural abnormalities or certain other conditions, such as tumors, inflammatory disease, congenital abnormalities, osteonecrosis, bone marrow disease, and herniation or degeneration of discs of the spinal cord
Blood Draws: Blood draw such as CBC and Erythrocyte sedimentation rate( ESR)can show serum levels of substances that can cause pain in the joints such as uric acid.
Differential Diagnosis: 1)
Patellar tendinitis: This is the most likely diagnosis based on the patients HPI, ROS, physical assessment, and diagnostic studies. The patient’s chief complaint was dull pain in the knees with occasional clicking in one or both knees. The patient is athletic and participates in many sports that constantly put strain on his knees. The quadriceps angle was greater than 10 which suggests patellar tendinitis. The patient plays sports that include a lot of running and jumping which adds strain to the knee joints. The patient was also positive for tenderness on palpation at the inferior pole of the patella bilaterally. Lastly, the MRI was positive for high signal intensity within the proximal posterior central aspect of the tendon where it originates from. 2)
Osgood Schlatter’s disease: A possible diagnosis as it is a common problem which typically occurs during times of fast growth usually in fit active boys. Osgood Schlatter’s disease is associated with pain just below the kneecap in one or both knees, often worse after sports especially high impact activities using the quadriceps muscles. However, limping is often a present and the patient denied limping in the ROS. Pain is greater with stair climbing and kneeling and the patient did not admit to either. Flexion and extension will increase pain in the tibial tubercle which was not present upon physical exam of the patient.
3) Chondramalacia patellae: This is a possible diagnosis due to the presence of knee pain upon palpitation and increased pain with activity. However, chondramalacia patellae is more common in females or persons with a history of knee trauma. The patient is male and denied trauma to either knee (Dains, Bauman & Schuber, 2016}. The patient denied a history of misalignment which is also related to chondramalacia patellae. An x-ray of the knee would show irregularities of the patellofemoral joint.
4) Medial meniscus tear: This diagnosis is a possibility because it can occur after a twisting injury and the patient participates in sports such as soccer, basketball, and skiing that involve twisting movements. Clicking may be present with a medial meniscus tear which the patient reported and was also appreciated upon physical assessment in the right knee. McMurray test was negative for locking during joint movement. The patient denied difficulty with weight bearing.
5) Juvenile rheumatoid arthritis (JRA): Possible due to knee joint soreness and stiffness, however both typically improve with activity. Joint swelling may also present with JRA and was reported by the patient in his ROS. Patient denied weight loss and fatigue which are common symptoms. Patient also denied night pain. A CBC would show anemia, leukocytosis, and thrombocytosis. The ESR would be elevated.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Rath, E., Schwarzkopf, R., & Richmond, J. (2010). Clinical signs and anatomical correlation of patellar tendinitis. Indian Journal of Orthopaedics, 44(4), 435-437 3p. doi:10.4103/0019-5413.69317
Conable, K. M., & Rosner, A. L. (2016). A narrative review of manual muscle testing and implications for muscle testing research. Journal of Chiropractic Medicine. doi:10.1016/j.jcm.2011.04.001
Manaster, B. J. (2017). Soft-Tissue Masses: Optimal Imaging Protocol and Reporting. American Journal of Roentgenology, 201(3), 505-514. doi:10.2214/ajr.13.10660
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