NSG 3012 Week 5 Discussion – Musculoskeletal and Neurologic System

Discuss Mr. Payne’s history that would be pertinent to his genitourinary problem. Include chief complaint, HPI, Social, Family, and Past medical history that would be important to know.

The patient, Mr. Payne, is a 45-year-old male truck driver who presents with complaints of sharp stabbing back pain after lifting a ten lb. box. The pain radiated down his left leg to the ankle. Factors that aggravate the pain include sitting while lying down in a supine position, which alleviates the pain. The patient has no history of trauma, chills or fever, night pain, urinary symptoms, or bladder or bowel incontinence. He has a medical history of hypertension, type 2 diabetes, and hyperlipidemia. His current medications include Metformin 1000 mg BID, Glyburide 10mg BID for diabetes, Amlodipine 2.5mg daily, Lisinopril 40mg daily for hypertension, and Simvastatin 40mg daily for hyperlipidemia. In regards to his social history, the patient is married with two daughters, quit smoking two years ago, occasionally drinks (on weekends), and denies the use of recreational drugs.

Describe the physical exam and diagnostic tools to be used for Mr. Payne. Are there any additional you would have liked to be included that were not?

A thorough physical examination should be performed to narrow down the differential diagnosis. Based on the physical exam findings, the patient’s vital signs were within normal limits. An abdominal examination is essential to help rule out gastrointestinal causes of back pain, such as abdominal aortic aneurysm and abdominal bruit (Buttaro et al., 2020). Auscultation using a stethoscope is essential to help rule out these two conditions, while palpation is also essential to assess the patient for signs of abdominal soreness. The rest of the physical exam was focused on the musculoskeletal system, including assessing the patient’s gait, ROM, and neurological testing. The examination was performed while the patient was standing, seated, and lying. The standing exam entailed inspection and palpation of the patient’s back, along with ROM exercises. The seated exam revealed that he had a normal curvature with tenderness on palpation of the left lumbar paraspinal muscle. He had a full ROM and reported pain with movement. A straight leg lift was performed to help rule out sciatic nerve issues and tight hamstrings. The second Faber test was also performed to assess the patient for abduction, external rotation, and flexion. Given that the patient’s history and assessment did not reveal any red flags of serious underlying pathology, there was no need for further diagnostic testing. Red flags for serious conditions in patients with low back pain that necessitate further testing include signs and symptoms of cancer such as history of cancer, night pain, pain at rest and unexplained weight, signs of infections including fever, recent bacterial infection, chronic steroid use and history of intravenous drug use, signs of Cauda Equina Syndrome including urinary incontinence, neurological deficits, and saddle anesthesia (Buttaro et al., 2020).

NSG 3012 Week 5 Discussion – Musculoskeletal and Neurologic System

Please list three differential diagnoses for Mr. Payne and explain why you chose them. What was your final diagnosis, and how did you make the determination?

The patient’s differential diagnosis should include disc herniation, lumber muscle strain, and degenerative arthritis. Disc herniation was the most probable diagnosis given that the condition is characterized by low back pain that has an acute presentation, precipitated by sudden injury, and pain that radiates down the leg and is worsened by sitting or flexing hips.

(Hall, 2021). The lumbar strain was considered since it is a major cause of acute lower back pain and is characterized by lower back pain associated with a mechanical injury (Urits et al., 2019). Also, in patients with lumber muscle strain, pain may radiate down to the legs and is worsened by particular movements or immobility. Degenerative arthritis was considered due to the patient’s age. Buchbinder et al. (2018) state that degenerative arthritis is prevalent among older patients, though it can occur in the early 40s. However, the condition was ruled out due to the absence of lower back pain with an insidious onset.

What plan of care will Mr. Payne be given at this visit, including drug therapy and treatments? What is the patient education and follow-up?

The goal of treatment in patients with lower back pain caused by disc herniation is to relieve symptoms and promote physical functioning. Pharmacologic treatment for the presented patient should include an oral NSAID or aspirin. According to Urits et al. (2019), the first-line medications for the treatment of lower back pain are NSAIDs, which have been shown to be effective for pain relief. NSAIDs should be used for a limited period of time (less than three months) to reduce the risk of side effects, including gastrointestinal bleeding ( Urits et al., 2019). For the presented patient, he can be prescribed naproxen 250 mg PO BID PRN or ibuprofen 400 mg PO every 6-8 hours PRN.

NSG 3012 Week 5 Discussion – Musculoskeletal and Neurologic System

The patient should also be referred for physical therapy. According to Buttaro et al. (2020), physical therapy with strengthening exercises has various positive effects on patients with lower back pain. Early entry into a physical therapy program, within six weeks after the onset of symptoms, helps reduce the progression of psychosocial features associated with low back pain, including anxiety and depression (Buttaro et al., 2020). Therapeutic modalities used in physical therapy, such as superficial heat, help promote pain relief and circulation to the affected area and improve healing.

Regarding patient education, it should start with reassurance, explaining the signs and symptoms of mechanical low back pain and, in most cases, resolve in a timely manner. Activity avoidance should be discouraged, given that being active helps improve outcomes in the treatment of low back pain (Buttaro et al., 2020). Lastly, the patient should be instructed to return to the clinic after a week for a follow-up visit or PRN if symptoms worsen.

References

Buchbinder, R., van Tulder, M., Öberg, B., Costa, L. M., Woolf, A., Schoene, M., … & Turner, J. A. (2018). Low back pain: a call for action. The Lancet, 391(10137), 2384- 2388.

Buttaro, T. M., Polgar-Bailey, P., Sandberg-Cook, J., Trybulski, J., & Distler, J. (Eds.). (2020). Primary Care: Interprofessional Collaborative Practice. Elsevier.

Hall, H. (2021). Low Back Patterns of Pain: Classification Based on Clinical Presentation. Handbook of Spine Technology, 3-25.

Urits, I., Burshtein, A., Sharma, M., Testa, L., Gold, P. A., Orhurhu, V., … & Kaye, A. D. (2019). Low back pain, a comprehensive review: pathophysiology, diagnosis, and treatment. Current pain and headache reports, 23(3), 1-10.

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This week, complete the Aquifer case titled “Family Medicine 10: 45- 45-year-old man with low back pain.” Apply information from the Aquifer Case Study to answer.