question archive 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

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

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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).

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