[ANSWERED] 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

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

The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provides the body with support and mobility.

Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams.

In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

To prepare:

• Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
• Review the following case study:

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?

Case 2: Ankle Pain

A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved?

What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottawa ankle rules to determine if you need additional testing?

Case 3: Knee Pain

A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain?

What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?

With regard to the case study you were assigned:

• Review this week’s Learning Resources, and consider the insights they provide about the case study.
• Consider what history would be necessary to collect from the patient in the case study you were assigned.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

Expert Answer

Episodic/Focused SOAP Note for Case #1 Back pain

Patient Information:

Initials, Age, Sex, Race

John Doe is a 42-year-old white male.

S.

CC “Pain in the lower back for the past month.”

HPI: John Doe is a 42-year-old white male who came to the clinic complaining of lower back pain for the past month. He notes that sometimes the pain radiates to his left leg. The pain started after sitting for 16 hours balancing his company’s budget five weeks ago. The pain often become sudden and make his legs weak. He has not taken any medication to alleviate the pain. He says that the severity of the pain can be scaled in a scale of 7/10.

Current Medications: No medications.

Allergies: No allergies.

PMHx: His pneumonia, influenza, and tetanus vaccines are up to date. The patient has no major medical condition.
Soc Hx: He married with three kids and likes listening to music and watching movies at his free time. He has been smoking two packets of cigarettes for the past 15 years. He denies alcohol use.

Fam Hx: His mother died aged 73 with type two diabetes. His father is alive but has heart problems. His other two younger siblings are healthy. His children are also healthy with no major conditions.

ROS:

GENERAL:  No chill, fever, fatigue, or weight loss.

HEENT:  Eyes:  No visual issues. Ears, Nose, Throat:  No hearing problems, sneezing, runny nose, or sore throat.

CARDIOVASCULAR:  No edema, chest pain, or palpitations.

RESPIRATORY:  No sputum, breathing problems, or cough.

GASTROINTESTINAL:  Reports pain in the lower back.

NEUROLOGICAL:  Reports occasional numbness or tingling of the leg extremities.

MUSCULOSKELETAL:  Reports pain in the lower back muscles

O.

Physical exam:

Constitutional: General Appearance: Healthy appearing adult male with moderate distress. Answers questions properly and is oriented and alert. Vitals: BP 136/90; P 88; R 20; T 36.3; W 92kgs; H 156cm.

HEENT: Head: Hair evenly distributed and head id normal cephalic. Eyes:  Extraocular movements intact, conjunctivae pink. Ears: Hearing intact, clear tympanic membranes on otoscopic. Nose: Clear mucus. Mouth: All teeth are present and in good shape. Throat: Tonsils are not swollen and have no lesions.

Heart: Regular rhythm and rate. No rubs or murmurs. Neck arteries have normal pulse.

Lungs: Chest walls are symmetric. Lungs are bilateral and clear to auscultation. Respiration easy and regular.

Abdomen: Positive straight leg test, no back tenderness, intact bilateral hip motion, unremarkable sensation and strength, negative crossed straight leg test. lumber spine is symmetrical.

Diagnostic results: The condition can be diagnosed using X-ray. Ball, Dains, Flynn, Solomon & Stewart (2019) note that X-ray can show the bone spur that may be pressing the nerve.

X-ray-Pending

A.

Differential Diagnoses

Sciatica:

Sciatica is the primary diagnosis for this case. sciatica is the pain that radiates along the sciatic nerve path, that branches to the lower back through the hips, down to the buttocks and legs (Stynes, Konstantinou, Ogollah, Hay & Dunn, 2018). The disease can also cause muscle weakness and tingling of the one or both legs.

This disease has been selected as the primary diagnosis because the patient feels pain in the lower back that radiates down to the left leg. Physical exam also shows that the patient might have sciatica. He is also obese, hence risks suffering the disease. Stynes et al. (2018) note that excess body weight can cause spinal changes that trigger the disease by increasing stress on the spine.

Lower Back Strain and Sprain:

This disease is one of the most common causes of lower back pain. One of its symptoms include lower back pain that radiate into to buttock but does not impact the legs (Dains, Baumann & Scheibel, 2019). The disease has been included in the diagnosis because the patient feels lower back pain. However, it has been excluded because it does not affect the legs.

Left-Sided Ulcerative Colitis:

Left-Sided Ulcerative Colitis is a disease that causes lasting inflammation and ulcers in the digestive tract (Sahami et al., 2017)). The disease can cause lower back pain that affects the left leg, and that is way the disease has been included in the diagnosis. However, it is not a primary diagnosis because the patient has no fever, diarrhea, or urgency to defecate.

Acute Severe Ulcerative Colitis:

Acute severe ulcerative colitis is characterized by the present of more than six bloody stool along with fever, and diarrhea. This disease also causes back pain that is so severe (Sahami et al., 2017). The disease has not a primary diagnosis because the patient id not bleeding.

Crohn’s Disease:

Crohn’s disease is an IBD that impacts the digestive tract by inflaming the digestive organs, hence leading to back pain, and that is why it has been included in the diagnosis (Rosen et al., 2017). However, it is not a primary diagnosis because the patient has no fever or digestive problems.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel\’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Rosen, M. J., Karns, R., Vallance, J. E., Bezold, R., Waddell, A., Collins, M. H., … & Baker, S. S. (2017). Mucosal expression of type 2 and type 17 immune response genes distinguishes ulcerative colitis from colon-only Crohn’s disease in treatment-naive pediatric patients. Gastroenterology, 152(6), 1345-1357. https://doi.org/10.1053/j.gastro.2017.01.016

Sahami, S., Konté, K., Buskens, C. J., Tanis, P. J., Löwenberg, M., Ponsioen, C. J., … & D’Haens, G. R. (2017). Risk factors for proximal disease extension and colectomy in left-sided ulcerative colitis. United European gastroenterology journal, 5(4), 554-562. https://doi.org/10.1177%2F2050640616679552

Stynes, S., Konstantinou, K., Ogollah, R., Hay, E. M., & Dunn, K. M. (2018). Clinical diagnostic model for sciatica developed in primary care patients with low back-related leg pain. PLoS One, 13(4), e0191852. https://doi.org/10.1371/journal.pone.0191852

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