Description
Apply information from the Aquifer Case Study to answer the following discussion questions: 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? CASE DESCRIPTION: Forty-five-year-old male truck driver complaining of two weeks of sharp, stabbing back pain after lifting a 10-lb. box. 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: Vital signs: 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: Smoked one pack per day for 20 years. Quit smoking two years ago, drinks one to two beers occasionally on the weekends, no history of IV drug use. Medication: Metformin 1000mg PO twice daily Glyburide 10mg PO twice daily Amlodipine 2.5 mg PO daily Lisinopril 40 mg PO daily Simvastatin 40 mg PO daily Allergies: No known drug allergies. Mr. Payne does not have numbness or weakness in his legs. The pain is better when he lies down. He has not had urinary frequency, dysuria, problems with bowel or bladder control, fever or chills, nausea or vomiting, or weight loss. He also reports no recent trauma or unrelenting night pain. Mr. Payne is a 45-year-old male truck driver with a two-week history of low back pain that radiates down his left leg to the ankle. The pain is worse with sitting and improves with the supine position. He denies history of trauma, fever/chills, night pain, urinary symptoms, and bowel or bladder incontinence. 1. Epidemiology and risk factors: 45-year-old male; occupation: truck driver 2. Key clinical findings about the present illness using qualifying adjectives and transformative language: pain present for two weeks pain radiates down left leg pain worse with sitting and improves with supine position no history of trauma no fever/chills no night pain no urinary symptoms no bowel or bladder incontinence Mr. Payne’s presentation of acute low back pain radiating to the leg that is worse with sitting is most consistent with either lumbar strain or lumbar radiculopathy, which are among the most common causes of low back pain. Lumbar radicular symptoms may be caused by any process that compresses a nerve root as it exits the spine. Causes include disc herniation, degenerative arthritis with osteophyte development, and spondylolisthesis. Degenerative arthritis is more common in older patients, though it can happen as early as one’s 40s, as in Mr. Payne. Spondylolisthesis can happen at any age. PHYSICAL EXAM: 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 reports no 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 5/5 strength throughout 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. Based on physical exam, you believe that Mr. Payne has back pain with radiculopathy, likely at the L5/S1 level. Given his risk factor as a truck driver and pain radiating down his leg, Mr. Payne’s pain is likely due to disc herniation. However, lumbar strain is still a possibility. Mr. Payne has no red flag symptoms to suggest an urgent need for imaging. Given that most radicular back pain, such as he has, resolves on its own within a month, it is most appropriate to avoid imaging in this situation. 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, and he is given a limited supply for seven days. Dr. Lee tells Mr. Payne about the side effects of both naproxen and codeine. 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. Three weeks later, Mr. Payne returns for his follow-up appointment and you discover the following: Pertinent History 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.