Risk of low back pain in those physically active vs those who lack physical active subjects
THE ASSIGNMENT TO BE COMPLETED (PLS PROVIDE SUBTITLES)
Respond to your colleague’s case study by doing the following.
• Analyze the possible conditions from your colleagues’ differential diagnoses.
• Determine which of the conditions you would reject and why.
• Identify the most likely condition and justify your reasoning.
• Support your paper with at least three current, credible sources within the last five years (1 from learning resources and 2 or more from outside).
GRADING RUBRIC:
• Response exhibits synthesis, critical thinking, and application to practice settings.
• Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.
• Demonstrates synthesis and understanding of Learning Objectives.
• Communication is professional and respectful to colleagues.
• Response is effectively written in standard, edited English.
COLLEAGUE’S CASE STUDY BY NICOLE COLLINS
Patient Information:
E.T., 42, Male, African-American
S.
CC (chief complaint) “I am having some pain in my lower back for the past month. It also sometimes shoots down my left leg”.
HPI: E.T. is a 42-year-old African-American male who presents on today with complaints of 7/10 lower back pain, radiating to his left leg. Pain is sharp, some tingling and achy at times. He c/o of pain for the last month. He reports no serious injuries that he can recall. He is a Fed-Ex delivery drive, which requires lots of pulling, lifting and bending. He is also active in the gym 4 times a week with exercising.
Location: lower back, left leg
Onset: 1 month ago
Character: sharp, tingling, achy
Associated signs and symptoms: laying on back, walking at work, sitting at work or in car driving
Timing: various times during the day and night, more frequently at night while sleeping
Exacerbating/ relieving factors: Ibuprofen prn for pain
Severity: 6/10 pain scale
Current Medications: Prilosec 20mg PO daily GERD; Epi-Pen prn for food allergies
Allergies: Peanuts, Nuts, Tree Nuts
PMHx: Immunizations up to date, Last tetanus 2015, Hx GI Lower GI Bleed- hospitalized x 4 days; received 2 units of packed red blood cells
Soc Hx: E.T. works as a Fed-Delivery driver, Married with 2 step children, does work on the side with home projects, loves attending concerts with his wife, and spending time with his family. Active in gym 4 times a week. Denies tobacco use, social drinker about 2-3 beers a week, occasional wine, E.T complies with safe driving always wearing seat beat, working smoke detectors in home, safe living environment, and no texting/ cellphone use while driving.
Fam Hx: Mother: Living age, 65- healthy, Father: Living age 67, Type 2 Diabetes (diet controlled and exercise), no siblings
ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. Denies abdominal pain or blood. Occasional heartburn after spicy food
GENITOURINARY: Denies burning with urination, denies drainage, discharge, denies incontinence, frequency, flank pain, malodorous urine, or color changes. Denies complications with sex.
NEUROLOGICAL: Reports numbness and tingling to left lower leg, denies headache, dizziness, syncope, paralysis, ataxia, in the extremities. Denies change in bowel or bladder control.
MUSCULOSKELETAL: Reports pain to lower back radiating to left leg
HEMATOLOGIC: Denies anemia, bleeding or bruising. Hx of GI bleed
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denis reports of sweating, cold or heat intolerance. Denies polyuria or polydipsia.
ALLERGIES: Peanut, Tree Nut, Nuts
O.
Physical exam:
Vital Signs: BP 134/87, HR 99, R 17, T 98.9, 02 99% RA, HT: 5’11” WT: 180lbs
General: well appearing 42 –year-old male, appropriately dressed, no distress
HEENT: PERRLA, symmetry head and face WNL, membranes moist, no lesions
Neck: Carotids no bruit, JVD
Chest/Lungs: clear to auscultation all fields, no wheezing. Room air
Heart/Peripheral Vascular: regular rhythm noted without murmur present, rub or gallop, pulses +2 bilateral pedal and radial.
Abdomen: soft, nontender, nondistended, + Bowel sounds x 4 quadrants
Genital/Rectal: external genitalia intact, no lesions, drainage, odors noted
Musculoskeletal: Str 5/5 x 4 ext, Rom of both upper and lower extremities, decreased movement and pain noted to left lower extremity, Normal spinal curvature, Sensory exam in the legs normal. Knee reflexes are reduced in left knee. Ankle reflexes are normal and symmetric. Paraspinal muscle spasm: mild there is severe midline tenderness. ROM of spine generally reduced, flexion reduced, extension reduced, lateral flexion to right normal, lateral flexion to left reduced, rotation to right normal, rotation to left reduced
Neurological: Cranial nerves grossly intact, strength normal, sensation normal
Skin: No edema, skin intact
Diagnostic results:
MRI- due to the pain for a month, and the radiation down his leg a MRI would be a good start. MRI testing is a good resource in evaluating soft tissue detail, such as disk herniations (Dains, Baumann, & Scheibel, 2019).
CT- is usually used for bone visualization. Being that we can’t actually see what damage may be present, I would send him for this as well.
Urinalysis with culture- to rule out any potential kidney infection, or kidney issues
CBC/BMP- Being that he has a history of GI bleed, checking a blood count wouldn’t be a bad idea as well as looking into potential infections as well. BMP would assess for any electrolyte imbalances as well as kidney function.
A.
Differential Diagnoses
1. Sciatica- Presents as low back-related leg pain, which is often characterized by pain radiating to below the knee and into the foot (Hider, Konstantinou, Hay, Glossop, & Mattey, 2019). A through patient history may disclose repetitive motion strain or strenuous lifting, twisting and bending, which in this patient’s case could be a potential cause (Dains et al., 2019).
2. Musculoskeletal strain (postural, overuse) When muscles and ligaments become inflamed from overuse or strain, a musculoskeletal strain could be a potential cause. History often reveals no precipitating event for the onset of pain. Patients may report that pain is alleviated by rest, especially in the supine position with hips and knees flexed, and by the application of heat or cold (Ball, Dains, Flynn, Solomon, & Stewart, 2019).
3. Compartment syndrome- acute compartment syndrome is an injury that involves both vascular integrity and neurological functioning. This condition develops when trauma to an extremity, often fractures to long bones, causes swelling and pressure that compromises blood flow to the affected muscles and nerves (Dains et al., 2019).
4. Herniated Disk- causes nerve root irritation and produces acute lower back pain that radiates down the buttock to below the knee. Pain is the prominent symptom, with numbness and weakness less common (Dains et al., 2019).
5. Stress fracture Stress fractures occur most often in the weight ¬bearing bones of the lower leg and foot. This type of fracture can occur in those who engage in high¬ intensity exercise (Dains et al., 2019). This patient is very active and work out performing high intensity interval training (HIIT), it possible there could have been some kind of fracture from this. In studies conducted, it has been found that individuals have an increased risk of low back pain in those physically active vs those who lack physical active subjects (Shiri, Solovieva, Husgafvel-Pursiainen, Telama, Yang, Viikari, Raitakari, & Viikari-Juntura, 2013).
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.
Hider, S. L., Konstantinou, K., Hay, E. M., Glossop, J., & Mattey, D. L. (2019). Inflammatory biomarkers do not distinguish between patients with sciatica and referred leg pain within a primary care population: results from a nested study within the ATLAS cohort. BMC Musculoskeletal Disorders, 20(1), 202. https://doi-org.ezp.waldenulibrary.org/10.1186/s12891-019-2604-2
Shiri, R., Solovieva, S., Husgafvel-Pursiainen, K., Telama, R., Yang, X., Viikari, J., Raitakari, O. T., & Viikari-Juntura, E. (2013). The role of obesity and physical activity in non-specific and radiating low back pain: The Young Finns study. Seminars in Arthritis and Rheumatism, 42(6), 640–650. https://doi-org.ezp.waldenulibrary.org/10.1016/j.semarthrit.2012.09.002
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.
LEARNING RESOURCES
• Chapter 4, “Vital Signs and Pain Assessment” (Previously read in Week 6)
• Chapter 22, “Musculoskeletal System”
This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system.
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.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 22, “Lower Extremity Limb Pain”
This chapter outlines how to take a focused history and perform a physical exam to determine the cause of limb pain. It includes a discussion of the most common tests used to assess musculoskeletal disorders.
Chapter 24, “Low Back Pain (Acute)”
The focus of this chapter is the identification of the causes of lower back pain. It includes suggested physical exams and potential diagnoses.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
• Chapter 2, “The Comprehensive History and Physical Exam” (“Muscle Strength Grading”) (Previously read in Weeks 1, 2, 3, 4, and 5)
• Chapter 3, “SOAP Notes”
This section explains the procedural knowledge needed to perform musculoskeletal procedures.
Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Musculoskeletal system: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Musculoskeletal system: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Katz, J. N., Lyons, N., Wolff, L. S., Silverman, J., Emrani, P., Holt, H. L., … Losina, E. (2011). Medical decision-making among Hispanics and non-Hispanic Whites with chronic back and knee pain: A qualitative study. BMC Musculoskeletal Disorders, 12(1), 78–85.
This study examines the medical decision making among Hispanics and non-Hispanic whites. The authors also analyze the preferred information sources used for making decisions in these populations.
Smuck, M., Kao, M., Brar, N., Martinez-Ith, A., Choi, J., & Tomkins-Lane, C. C. (2014). Does physical activity influence the relationship between low back pain and obesity? The Spine Journal, 14(2), 209–216. doi:10.1016/j.spinee.2013.11.010
Shiri, R., Solovieva, S., Husgafvel-Pursiainen, K., Telama, R., Yang, X., Viikari, J., Raitakari, O. T., & Viikari-Juntura, E. (2013). The role of obesity and physical activity in non-specific and radiating low back pain: The Young Finns study. Seminars in Arthritis & Rheumatism, 42(6), 640–650. doi:10.1016/j.semarthrit.2012.09.002
Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
• Chapter 13, “The Spine, Pelvis, and Extremities” (pp. 585–682)
In this chapter, the authors explain the physiology of the spine, pelvis, and extremities. The chapter also describes how to examine the spine, pelvis, and extremities.
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