Chief complaint: My back hurts so bad I can barely walk”   History of present: A 35-year-old male painter presents to your clinic with the complaint of low back pain

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Chief complaint:

My back hurts so bad I can barely walk”

 

History of present:

A 35-year-old male painter presents to your clinic with the complaint of low back pain. He recalls lifting a 5-gallon paint can and felt an immediate pull in the lower right side of his back. This happened 2 days ago and he had the weekend to rest, but after taking Motrin and using heat, he has not seen any improvement. His pain is sharp, stabbing, and he scored it as a 9 on a scale of 0 to 10.

Drug History:

Motrin for pain.

 

Family History:

Father hypertension
Mother DM

Subjective:

He is having some right leg pain but no bowel or bladder changes. No numbness or tingling

Objective

V/S

temperature: 98.2°F, respiratory rate 16, heart rate 90, blood pressure 120/60
O2 saturation 98%

General

well-developed healthy 35-year-old male; no gross deformities

HEENT

Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries.

Lung

CTA AP&L

Cardio:

S1S2 without rub or gallop

Breast:

• INSPECTION: no dimpling or abnormalities noted upon inspection
• PALPATION: Left breast - no abnormalities noted. Right breast - denies tenderness, pain, no abnormalities noted.

Lymph:

no bruising, fever, or swelling noted, no acute bleeding or trauma to skin.

Abdomen

benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.

Grastrounirnary:

Bladder is non-distended.

Integument:

intact without lesions masses or rashes.

MS

No obvious deformities, masses, or discoloration. Palpable pain noted at the right lower lumbar region. No palpable spasms. ROM limited to forward bending 10 inches from floor; able to bend side to side but had difficulty twisting and going into extension.

Neuro:

 

DTRs 2+ lower sensory neurology intact to light touch and patient able to toe and heel walk. Gait was stable and no limping noted.

Answer the following questions:

• What other subjective data would you obtain?
• What other objective findings would you look for?
• What diagnostic exams do you want to order?
• Name 3 differential diagnoses based on this patient presenting symptoms?
• Give rationales for your each differential diagnosis.
• What teachings will you provide?