· Discuss the Mr. Payne’s history that would be pertinent to his genitourinary problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
· Describe the physical exam and diagnostic tools to be used for Mr. Payne. Are there any additional you would have liked to be included that were not?
· Please list 3 differential diagnoses for Mr. Payne and explain why you chose them. What was your final diagnosis and how did you make the determination?
· What plan of care will Mr. Payne be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
Forty-five-year-old white male truck driver complaining of two weeks of sharp, stabbing back pain. The pain was better after a couple of days but then got worse after playing softball with his daughter. This morning his pain is so bad that he had trouble getting out of bed.
You and Dr. Lee take a few minutes to review Mr. Payne’s chart:
· Temperature: 98.6° Fahrenheit
· Heart rate: 80 beats/minute
· Respiratory rate: 12 breaths/minute
· Blood pressure: 130/82 mmHg
· Weight: 170 pounds
· Body Mass Index: 24 kg/m2
Past Medical History: Diabetes, well controlled. Hypertension, fair control. Hyperlipidemia, fair control.
Past Surgical History: None
Social History: Works as a truck driver, which involves lifting 20-35 lbs 4 hours of the day, married with 2 daughters,
Habits: Quit smoking two years ago, drinks 1 to 2 beers occasionally on the weekends, no history of IV drug use.
· metformin 500mg 2 twice daily
· glyburide 5mg 2 twice daily
· amlodipine 2.5 mg daily
· lisinopril 40 mg daily
· simavastin 40 mg daily
Allergies: No known drug allergies.
Can you tell me about your back pain?”
“As I told the nurse, the pain started two weeks ago after I lifted a box at work. Right away, I got this sharp pain on the left side of my back. The box wasn’t even that heavy.
“I talked to the nurse at work; she said to ice it and to take ibuprofen. It got better after three days. But, I was playing softball with my daughter last weekend, and the pain came back. This time it was worse than before. This week, the pain is so bad I can hardly get out of bed. I get a sharp pain in my back which goes down my left leg to my ankle.”
“On a scale of 0 to 10, 10 being the worst, how severe is the pain?”
“It’s probably a 7.”
“Have you found anything that improves the pain?”
“Ibuprofen and Naproxen worked at first, but they are not helping much anymore.”
“What about positions that make things better or worse?”
“The pain is worse with any movement of my back or sitting for a long time. It is better when I lie down.”
“Have you had back pain before?”
“Yes, I have back pain from time to time. But I’m usually better after 2 to 3 days. This is the worst pain I have ever had.”
Review of Systems
Mr. Payne does not have numbness or weakness in his legs. The pain is better when he lies down. He denies urinary frequency, dysuria, problems with bowel or bladder control, fever or chills, nausea or vomiting, or weight loss. He denies any specific trauma, except for when he lifted a 10-pound box at work. He denies unrelenting night pain.
Based on your differential, you determine that it is highly likely that Mr. Payne is experiencing a mechanical cause of back pain with nerve involvement such as a disc herniation. It is possible that he has spinal fracture, but a lack of trauma history makes the latter unlikely. It is important to consider cauda equina syndrome, as it calls for immediate surgical investigation, but it is unlikely in the absence of neurological symptoms like loss of bowel or bladder control. Finally, infectious etiology, such as pyelonephritis, is unlikely without fever and chills, urinary frequency and dysuria.
Back Exam – Standing:
Mr. Payne has normal curvature, tenderness on palpation on the left lumbar paraspinous muscle with increase tone. Full range of motion, but has pain with movement. His gait is normal. He can walk on his heels and toes. He can do deep knee bends.
Back Exam – Seated:
Mr. Payne denies feeling pain when checked for CVA tenderness. He has no pain in his right leg with the modified version of SLR. While he does not exhibit a true tripod sign, he does complain of pain when his left leg is raised. Mr. Payne’s reflexes are 2+ and equal at the knees and 1+ at both ankles. The motor exam reveals no weakness of the muscles of the lower extremities. His sensory exam is normal.
Pulmonary Exam: His lungs are clear.
Cardiovascular Exam: His cardiac exam demonstrates a regular rhythm, no murmur or gallop.
Three weeks later, Mr. Payne returns for his follow-up appointment and you discover the following:
Mr. Payne has had little relief with the treatment prescribed. He is frustrated that he has been in pain for more than a month. His pain has been progressively worse. It radiates down the lateral part of his left leg and side of his left foot. This pain is worse than the back pain. He does not have any problems with bowel or bladder control and there is no weakness of his leg.
Pertinent Exam Findings
Vital signs: stable
Neurologic: Normal gait, but moves slowly due to pain; range of motion is full, with pain on flexion; SLR is positive at 45 degree on the left; motor strength intact; reflexes 2+ bilaterally at the knees, absent at the left ankle, 1+ at the right ankle.
Dr. Lee agrees with your diagnosis of radiculopathy of S1 nerve root with progression. She orders an MRI and sets up an appointment to see Mr. Payne after the MRI.
You and Dr. Lee now return to Mr. Payne’s exam room to talk about treatment options with him. Dr. Lee tells Mr. Payne to avoid strenuous activities but to remain active. Dr. Lee increases the dosage of naproxen to 500 mg BID to take with food. Since his pain is intense (7/10), he is given a prescription for acetaminophen with codeine to take at night, when his pain is severe. Mr. Payne declines a muscle relaxant because they usually make him drowsy. He would like to be referred to physical therapy as it was helpful in the past.
One week later, Mr. Payne returns for follow-up. You review the results of the MRI report.
1. Moderate-size, herniated disc at L5-S1 with associated marked impingement on the left S1 nerve root and mild to moderate impingement on the right S1 nerve root. There is mild central canal stenosis.
2. Annular tear with a small central disc herniation at L4-5 causing mild central canal stenosis.
You review the findings with Dr. Lee. She agrees with your diagnosis of radiculopathy of S1 nerve root due to a large herniated disc at L5-S1.
You call Mr. Payne two weeks later to see how he is doing. He reports that he is doing quite a bit better. He went to an osteopathic physician who did some manual therapy and started him on a strict walking program. He is very encouraged and plans on losing weight through exercise and diet.