Case Study 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.
Episodic/Focused SOAP Note
Patient Information:
Patient Initials: M.R. Age: 42 years Sex: Male Race: White
Subjective
CC: “I have lower back pain which has persisted for almost a month”
HPI: MR is a 42-year-old white male who has reported to the clinic unaccompanied. He reports lower back pain that has persisted for about a month. MR indicates that his back pain sometimes radiates down his left leg. Physical activity and a heavy load worsen the pain while the pain is relieved with slight massage and Tylenol. MR denies an association of his back pain with a recent traumatic event. He further reports that the degree of pain is severe and it can be rated as 7/10 on the pain scale.
Location: Lower back.
Onset: 1 month ago.
Character: Aching.
Associated signs and symptoms: None.
Timing: Persistent.
Exacerbating/ relieving factors: Physical activity and a heavy load exacerbate the pain while Tylenol and slight massage relieve the pain.
Severity: 7/10 on the pain scale.
Current Medications: 500 mg Tylenol, 2 tablets taken after every 6 hours.
Allergies: No known allergies reported.
PMHx: Insomnia and Hypertension. M.R. does not remember when he received last tetanus vaccination. He received influenza vaccine 7 days ago. Denies previous surgeries or hospitalizations.
Soc Hx: Certified accountant working in a nearby manufacturing company. Married with 2 sons (12 years old and 17 years old). M.R. reports walking to work daily. He does not use tobacco, alcohol, or illicit drugs.
Fam Hx: Mother is 69 years old and was diagnosed with type 2 diabetes 2 years ago. Father is 74 years old and has hypertension. M.R. has two siblings and both are healthy. Maternal and paternal grandparents are deceased and he cannot remember their causes of death. His two sons are healthy.
Review of Systems
GENERAL: Denies weight loss or abnormal weight gain. Denies fever, chills, weakness or fatigue.
HEENT: Head: Denies head trauma or headaches. Eyes: Denies visual loss, blurred vision, or double vision. Ears: Denies ear pain or hearing loss. Nose: Denies sneezing, congestion, or runny nose. Throat: Denies sore throat.
SKIN: Denies rash, lesions, or itching.
CARDIOVASCULAR: Denies chest pain, chest tightness, or chest discomfort.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Does not report anorexia, nausea, vomiting or diarrhea. Denies abdominal pain.
GENITOURINARY: Denies burning sensation during urination.
NEUROLOGICAL: Reports numbness in the left lower leg. Denies dizziness or abnormal changes in bowel or bladder control.
MUSCULOSKELETAL: Reports persistent lower back pain that radiates to the left leg. The pain worsens with a heavy load and physical activity. It is relieved by massage and Tylenol medication.
HEMATOLOGIC: Denies anemia, abnormal bleeding or easy bruising.
LYMPHATICS: Denies enlarged nodes. Denies a history of splenectomy.
PSYCHIATRIC: Denies depression or anxiety. Denies previous suicide ideation or attempts.
ENDOCRINOLOGIC: Denies abnormal sweating at night. Denies cold or heat intolerance. Does not report a history of polydipsia or polyuria.
ALLERGIES: Does not report any allergies.
Objective
Physical exam:
VITAL SIGNS: Heart rate: 90 bpm. Blood pressure: 130/88. Respiration rate: 20. Temperature 37.2
GENERAL: M.R. is neatly dressed. He is perfectly oriented to time, place, and person.
CARDIOVASCULAR: No rub or gallop. Regular heart rhythm. (S1, S2). No carotid bruits noted.
RESPIRATORY: No wheezing or coarse noted. Symmetrical chest expansion and contraction during inhalation and exhalation respectively.
MUSCULOSKELETAL: Full range of motion noted in all extremities.
NEUROLOGICAL: Awake, alert, and oriented x 3. Speech is clear and fluent.
Cranial Nerves
CN II: Fundoscopic exam is normal with sharp discs and no vascular changes. Visual fields are full to confrontation. Visual acuity is 20/20 bilaterally.
CN III, IV, VI: No ptosis observed. Central and peripheral vision intact.
CN V: Intact corneal responses. Intact facial sensation to pinprick in all 3 divisions bilaterally.
CN VII: Normal eye closure and smile. Face is symmetric
CN VII: Good sensation to sound and hearing.
CN IX, X: Palate elevates symmetrically.
CN XI: Intact head turning and shoulder shrug observed.
CN XII: Tongue is midline. No atrophy.
Motor:
No pronator drift of out-stretched arms. Muscle strength is full bilaterally.
Reflexes:
Reflexes are 2+ and symmetric at the biceps, triceps, knees, and ankles.
Sensory:
Light touch, pinprick, and vibration sense are intact in fingers and toes.
Coordination:
Intact finger movements are noted. No Romberg noted.
Diagnostic tests:
- X-ray of the lower back: To establish whether there are any fractures (Traeger et al., 2017).
- Lasegue’s sign testing: To establish the presence of lumbosacral nerve root irritation (Traeger et al., 2017).
- MRI scan: To view soft tissues, nerve roots, and the spinal cord (Traeger et al., 2017).
- Electromyography: To examine the activity of electrical impulses through the sciatic nerve (Traeger et al., 2017).
Assessment
Differential Diagnoses:
Acute sciatic pain/Sciatica (primary diagnosis): Patients with sciatica commonly present with low back pain that radiates to the leg. The condition is usually considered for lower back pain that has persisted for less than two months (Stynes et al., 2018). Tingling and numbness occurs on the affected leg. Pain is worsened by walking, physical activity, and standing. A herniated disc is evidenced during radiographic tests.
Spinal disc stenosis: Lower back pain that radiates to the lower limbs is commonly reported by patients with spinal disc stenosis. Walking and standing worsens the pain (Cameron, 2021).
Spondylolisthesis: The condition usually causes a slip of one vertebral body over one below due to degenerative changes. Patients usually present with a combination of low back pain, neurogenic claudication, and radiculopathy (Xiang et al., 2017).
Lumbosacral Radiculopathy: The condition occurs sue to the compression of nerve roots in the lower back. Common symptoms include low back pain that radiates into the lower extremities (Alexander & Varcello, 2019).
Osteomyelitis of the spine: Pain the lower back can occur due to infections of the spine and bones (Andrade & Soares, 2019).
References
Alexander, C.E., & Varacello, M. (2019). Lumbosacral radiculopathy. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK430837/
Andrade, M. J., & Soares, T. F. (2019). The importance of the clinical examination of the lower sacral segments: Four case reports. The Journal of Spinal Cord Medicine, 42(1), 123–127. https://doi.org/10.1080/10790268.2018.1432306
Cameron, G. (2021). The assessment of lower back pain in primary care
or family practice. https://www.jointenterprise.co.uk/backpain-1.htm
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.
Traeger, A., Buchbinder, R., Harris, I., & Maher, C. (2017). Diagnosis and management of low-back pain in primary care. CMAJ: Canadian Medical Association Journal = journal de l’Association Medicale Canadienne, 189(45), E1386–E1395. https://doi.org/10.1503/cmaj.170527
Xiang, Y., Wang, J., Kaplar, Z., Deng, M., & Leung, C.S. (2017). Lumbar degenerative spondylolisthesis epidemiology: A systematic review with a focus on gender-specific and age-specific prevalence. Journal of Orthopaedic Translation, 11, 39-52.