Patient Initials

RD

Patient Age

72 y/o

Patient Gender

Female

Chief Complaint (CC)

[in quotation marks]

“I’ve had terrible back pain for two weeks.  I was moving into a condo last month and tripped while carrying a box and landed on my backside”

History of Present Illness (HPI)

Onset approx. 2 weeks ago, pain constant in duration in low back bilateral with spasms, and electric like radiation to RLE, pain varies from 2-7– today at 6.   Impacting sleep as she cannot get comfortable.  

Worsening occurs with bending or twisting.  She has used IBU 400mg 1 tab po daily for the last 8 days, heating pad.  Minimal relief of pain. 

She is not completing her normal 2 mile walks as a result of the pain.

Allergies

NKDA

(Brief) Past Medical History (PMH)

HTN – taking Lisinopril-HCTZ 10mg/12.5mg with good compliance

Osteopenia

2014 right wrist fracture

Nephrolithiasis 2007, 2010, 2016

Breast CA with left mastectomy 2002

(Pertinent) Family History

None

(Pertinent) Personal/Social History

Widowed, lives alone, 3 children and grandchildren in area

Wine, 1-2 glasses 3-4 nights weekly

Non-smoker

OBJECTIVE

Vital Signs

T = 97.6 F, HR = 66, RR = 18, BP =126/78, Height = 142cm Weight = 60 kg

Physical Exam (PE):

1.       General appearance (neuro)

2.       SHEENT

3.       Cor/Chest

4.       Abd/GU

5.       Extremities

General: Well developed, well nourished; in no acute distress; appears stated age. Seems uncomfortable in chair.  Guards position changes. 

1

HEENT: Normocephalic without masses or lesions; pupils equal, round, and reactive to light; extraocular movements intact; turbinates pink; throat without redness or lesions, uvula midline

Neck: Supple without thyromegaly or adenopathy

Respiratory: CTAB, no rhonchi, no wheezes; symmetrical resonant percussion

Heart: S1S2, RRR, no murmurs, rubs, gallops

Abdominal: No hepatosplenomegaly; abdomen soft, nontender; bowel sounds normoactive

Genitourinary: No CVAT

Extremities: Range of motion functionally intact; no cyanosis, clubbing, or edema.

Neurological: Reflexes 2+ at Achilles, patellar. Gait stable.

MSK:  normal ROM neck, hips, shoulders.  Strength equal in BUE &  BLE,

Back: Pain worsens with flexion & extension. 

    Palpation: Increased muscle tension l3-l5 paraspinals, Pain paraspinals of lower lumbar spine, right SI pain with deep palp.

    Negative SLR

ASSESSMENT

PLAN

Diagnostics?

[5 points]

The diagnostics to be considered or ordered should be a reflection of the clinical practice guidelines and any additional diagnostics that pertain to the ca

Questions (All answers should have a source cited)

1. The patient returns in 4 weeks as directed. She has little improvement in symptoms.  She stopped PT as she felt it was not improving.  What will you update in her plan of care today? [2.5 points]

My Response

1. Opioids administration for short-term relief of pain since IBU 400mg 1 tab PO daily had minimal effect in relief of her lower back pain (Will et al., 2018). Morphine sulfate 15 mg PO every 12 hours (Prescribers’ Digital Reference, 2020).
2. Administration of skeletal muscle relaxants (Will et al., 2018).

2. Briefly discuss physical exam elements to be performed pertinent to a pt with reports of back pain and why/what it may indicate. Include sources outside of AAFP article.  [10 points]

My Response

1. Assessment of the nature of the pain: Evaluating the patient for the possibility of neuropathic pain. Neuropathic pain syndrome is commonly associated with chronic lumbar radicular pain (Pergolizzi & LeQuang, 2020). Neuropathic lower back pain is associated with depression and more anxiety, lower quality of life, greater disability, and greater pain intensity compared with nociceptive pain. The widespread and diffuse nature of the pain may be positive for neuropathic pain (Pergolizzi & LeQuang, 2020).
2. Patrick’s test or straight leg raise: to differentiate the origin of the lower back pain (Casiano, Dydyk, & Varacallo, 2020). Lumbar disc herniation is indicated by ipsilateral leg pain at <60° leg raise (Casiano et al., 2020).
3. Identify relieving and exacerbating factors (Casiano et al., 2020).
4. Assess the patient for associated symptoms such as bladder or bowel changes, difficulty in ambulation, weakness, chills, fever, sensation changes, and unexplained weight loss (Casiano et al., 2020).
5. Inspection, strength testing, palpation, neurologic (deep tendon reflex, limb strength, and sensation) assessments, and provocative maneuvers (Casiano et al., 2020).
6. One leg hyperextension test/stork test: pain that occurs with hyperextension of the one leg indicates pars interarticularis defect (Casiano et al., 2020).
7. Adam test: if thoracic lump is present on either side then it may be positive for scoliosis (Casiano et al., 2020).
8. Assess the lumbar spine for abrasions, contusions, and tenderness to palpitation of the spinous-process since it may be positive for lumbar spine fracture (Casiano et al., 2020).
9. Explain the different imaging options for a back injury. When would you order each option? What are the criteria according to The American College of Radiology Appropriateness Criteria? [10 points]

My Response

1. X-ray lumbar spine: since the pain has persisted for more than 6 weeks (Casiano et al., 2020). X-ray imaging is recommended for initial imaging examination, particularly in patients with history of steroid use or osteoporosis (American College of Radiology (ACR), 2015).
2. MRI of the thoracolumbar spine without IV contrast: to identify possible spinal stenosis or disc herniation (Casiano et al., 2020). It is useful in evaluation of worsening neurologic deficit or ligamentous injury. MRI can show marrow edema (ACR, 2015).
3. CT lumbar spine without IV contrast: since there is a concern for fracture of the vertebral body following the fall (ACR, 2015).
4. Tc-99m bone scan with SPECT spine: for detection and localization of painful pseudodarthrosis (ACR, 2015).

se.

1.       Physical examination for abrasions or contusions to assess for fracture (Will et al., 2018).

2.       Assess the patient and identify red flags such as spine fracture, infection, cauda equine syndrome, and/or malignancy (Will et al., 2018).

3.       Order imaging studies if there is concern for malignancy, cauda equina syndrome, infection, and/or fracture (Will et al., 2018).

4.       Assess the patient for radiculopathy (Will et al., 2018).