[ANSWERED 2024] Post an episodic focused note about the patient in the case study to which you were assigned using the episodic/focused note template

Post an episodic focused note about the patient in the case study to which you were assigned

Case Study:

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?

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 and Explanation

SOAP Note

Patient Information:

S.

CC “pain in the lower back.”

HPI: Patient BB is a 42-year-old male who has visited the hospital complaining of lower back pain that has occurred for the past month. The patient reports that the pain may be severe in the left leg. The pain was measured to be a scale of 7/10. The pain started moments after he had got out of bed one month ago and it has not gone away since then.

Current Medications: Tylenol tablets.

Allergies: Allergic to aspirin.

PMHx: He got influenza vaccination three months ago.

Fam Hx: His father died of kidney failure and his mother has HBP.

ROS:

GENERAL: The patient feels lower back pain that extends to the left leg.

HEENT: No hearing or visual loss, no running nose, and no sore throat.

CARDIOVASCULAR:  Has HBP.

RESPIRATORY:  No sputum.

MUSCULOSKELETAL: Pain in the lower back that extends to the left leg.

O.

Physical exam: During physical examination it was found that the patient felt pain in forward flexion when he was moving. Also, palpation showed that there is a fracture in the area around the lower spine.

Diagnostic results: Urinalysis test was conducted to find whether the patient had kidney infection (Petersen et al., 2017).

A.

Differential Diagnoses 

Fracture of the Lumbar Vertebral Body– Most possible condition

Inflammatory Conditions

Kidney Infection

Ulcer

Epidural Infection

Reason for Selecting Lateral Ligament Injury

The above diseases have been selected as the diagnoses for the disease because they all cause back pain (Verhagen et al., 2017). However, fracture of the lumbar vertebral body is the primary diagnosis due to the following reasons. According to Lipani (2017), fracture of the lumbar vertebral body can cause back pain by pinching or damaging the lower spine. Physical exam of Mr. C showed that he had fracture in the lower spine, and this has made the disease the most possible condition.

References

Lipani, J. D. (2017). U.S. Patent No. 9,630,011. Washington, DC: U.S. Patent and Trademark Office. https://patents.google.com/patent/US9630011B2/enaa

Petersen, T., Laslett, M., & Juhl, C. (2017). Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews. BMC musculoskeletal disorders, 18(1), 188. https://link.springer.com/article/10.1186/s12891-017-1549-6

Verhagen, A. P., Downie, A., Maher, C. G., & Koes, B. W. (2017). Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review. Pain, 158(10), 1860-1868. doi: 10.1097/j.pain.0000000000000998

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FAQs

What is the condition causing pain in the lower back and leg?

Sciatica is a term used to describe pain that radiates along the path of the sciatic nerve, which runs from the lower back through the buttocks and down each leg. The pain is typically caused by compression or irritation of the sciatic nerve. Common causes of sciatica include:

1. Herniated Disc: When the soft inner core of a spinal disc pushes through the tough outer layer and irritates or compresses the nearby nerve roots.
2. Spinal Stenosis: The narrowing of the spinal canal, which can put pressure on the spinal cord and nerves.
3. Degenerative Disc Disease: The breakdown of discs in the spine, often associated with aging.
4. Spondylolisthesis: When a vertebra slips forward over the vertebra below it, causing pressure on the nerves.
5. Piriformis Syndrome: Irritation of the piriformis muscle, which can cause it to press against the sciatic nerve.
6. Muscle Strain: Overuse or injury to the muscles and ligaments supporting the spine.

What nerve roots might be involved in the cause of the back pain based on your knowledge of anatomy?

Lower back pain and leg pain, particularly associated with sciatica, often involve nerve roots in the lumbar (lower) and sacral (pelvic) regions of the spine. The specific nerve roots that may be involved depend on the underlying cause of the pain. Here are the nerve roots typically associated with lower back pain and sciatica:

1. L4 (Lumbar 4): Pain or discomfort may radiate to the thigh and sometimes the lower leg.
2. L5 (Lumbar 5): Pain can extend from the lower back to the back of the thigh and down the leg. It may also affect the top of the foot.
3. S1 (Sacral 1): Pain may radiate from the lower back down the back of the thigh and calf, possibly reaching the outer side or sole of the foot.

These nerve roots make up part of the sciatic nerve, which is formed by the combination of nerve roots from the lower spine. Compression or irritation of these nerve roots can lead to the characteristic symptoms of sciatica, including lower back pain that radiates down the buttocks and into one or both legs.

What causes lower back pain in your 40s?

Lower back pain in your 40s can be caused by various factors, and it often results from a combination of factors rather than a single cause. Common contributors to lower back pain in this age group include:

1. Muscle Strain: Overuse or improper use of the muscles supporting the spine can lead to strain and pain. This may be related to poor posture, lifting heavy objects incorrectly, or engaging in activities that put excessive stress on the back.
2. Degenerative Disc Disease: As people age, the intervertebral discs in the spine can naturally degenerate, losing some of their cushioning ability. This can lead to pain, stiffness, and decreased flexibility in the lower back.
3. Herniated Disc: A herniated or slipped disc occurs when the soft inner core of a spinal disc protrudes through the tough outer layer, irritating nearby nerves. This can cause pain in the lower back and may also lead to sciatica with pain radiating down the leg.
4. Osteoarthritis: Wear and tear on the joints of the spine can lead to osteoarthritis, causing pain and stiffness in the lower back.
5. Spondylosis or Spondylolisthesis: These are conditions where there is degeneration or displacement of the vertebrae in the spine, which can result in lower back pain.
6. Lifestyle Factors: Sedentary lifestyles, lack of regular exercise, and poor posture can contribute to lower back pain. Maintaining a healthy weight and staying active can help prevent or alleviate pain.
7. Stress and Emotional Factors: Stress and emotional well-being can impact physical health, including back pain. Chronic stress may contribute to muscle tension and exacerbate existing conditions.
8. Medical Conditions: Certain medical conditions such as fibromyalgia, endometriosis (in women), or kidney problems can cause lower back pain.