Case 1: Back Pain
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?
With regard to the case study you were assigned:
- Consider what history would be necessary to collect from the patient in the case study
you were assigned. - Consider what physical exams and diagnostic tests would be appropriate to gather more
information about the patient’s condition. How would the results be used to make a
diagnosis? - Identify at least five possible conditions that may be considered in a differential diagnosis
for the patient.
** Write a description of the health history you would need to collect from the patient in
the case study to which you were assigned. Explain what physical exams and diagnostic
tests would be appropriate and how the results would be used to make a diagnosis. List five
different possible conditions for the patient’s differential diagnosis, and justify why you
selected each.
Use Resource that is less than five years old.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2012). Advanced health assessment and
clinical diagnosis in primary care (4th ed.). St. Louis, MO: Mosby, Elsevier. Chapter 21,
“Low Back Pain (Acute)” (pp. 267-279)
Back Pain
History
The patient’s bone tone, muscle elasticity, and strength should be assessed. The patient
should discuss the kind of work he does and the daily activities he engages in so as to establish
whether he suffered a spasm, strain, or sprain after overstretching or lifting heavy objects. As a
result of this, the nerve roots that are based in the spinal cord may be under too much pressure. It
should be established if the patient is suffering from a degenerative condition, bone lesion, or
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muscle or nerve irritation (Lee, Brook & Daniel, 2009). Other factors that should be established
in the patient include poor physical condition, stress, smoking habits, obesity, inappropriate
posture when performing any activity, as well as poor sleeping positions. The healthcare
provider should also assess if the patient has any scar tissues. The patient should be asked if he
suffers from any conditions such as diabetes or if he experiences pain that is associated with pain
when coughing, fever, and loss of bladder or bowel control, as well as progressive leg weakness,
which may be an indication of other critical conditions or a pinched nerve (Dains, Baumann &
Scheibel, 2012).
It is important to establish if after the pain began, it has affected the routine daily
activities, work, recreation, quality of life, sleep and productivity. Again, it should be assessed if
the pain has been continuous for the one month or it comes and goes, which will assist in
labeling it as chronic or acute. The patient should be asked what occurred to him that brought
about the back pain (Lee, Brook & Daniel, 2009).
Diagnostic tests and physical exams and making a diagnosis
Diagnostic tests are important in that they confirm the anatomical lesion (any disease or
abnormality) as the cause of the pain. More particularly, these tests help in pinpointing the
lesion’s extent and source (degree of spondylolithesis, degenerated disc, or herniated disc),
which is useful in making the diagnosis and developing a proper treatment plan. X-rays will be
useful in providing a detailed spine’s bone structure and checking for instability
(spondylolisthesis), fractures, and tumors (Dains, Baumann & Scheibel, 2012). CT scans
provide an excellent bony detail and can assist in imaging particular conditions including spinal
stenosis and herniated disc. MRI scans help in assessing for certain conditions by offering details
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of the disc (isthmic spondylolisthesis and degenerative disc disease) and nerve roots (spinal
stenosis and herniated discs). They also assist in ruling out tumors and spinal infections.
During the physical examination, the healthcare provider should ask the patient to
perform a series of movements as he lies down, sits, and stands. This way, assessing for sensory
or muscular problems becomes easier. It should involve measurements and observations;
palpitation where the provider feels for joint alignment and tenderness and checks leg pulses; the
legs’ and trunk’s general exam, nerve tests, and certain tests such as the straight leg test. This
establishes if the pain and symptoms are because of nerve pressure and the nerves that are
compressed. This will assist in determining the most effective treatments (Lee, Brook & Daniel,
2009).
Conditions in a differential diagnosis
Spinal stenosis; pain radiating to the leg and lower extremities’ weakness. The patients
could also be suffering from Radiculopathy ot sciatica where pain radiates to the leg and there
is lower extremities’ weakness. The patient could also be suffering from Isthmic
spondylolisthesis as there is pain extending to the thigh. With lumbar facet arthropathy, pain also
radiates to the legs. The back pain may be as a result of lumbar compression fracture (Lee, Brook
& Daniel, 2009).
References
Dains, J. E., Baumann, L. C., & Scheibel, P. (2012). Advanced health assessment and clinical
diagnosis in primary care (4th ed.). St. Louis, MO: Mosby, Elsevier. Chapter 21, “Low
Back Pain (Acute)” (pp. 267–279)
Lee, J., Brook, S., & Daniel, C. (2009). Back pain (1st ed.). Oxford: Oxford University Press.