Question

Jack is a 45 year old construction worker who is complaining of low back pain since injuring himself at work today. Today as he was lifting a sheet of plywood he suddenly felt excruciating pain in his right lower back and pain down his right leg. He has suffered back injuries on the job 3 times in the past 3 years and was prescribed Motrin and muscle relaxants in Urgent Care with rest for 3 days after which he resumed his normal routine. PMHx includes hypertension for past 5 years treated with a diuretic. Surgical history includes appendectomy at age 20 and vasectomy at age 32. Family history negative with the exception of PGP deceased from MI at age 55.
NKDA. Current meds: HCTZ 25 mg daily.
Virtually assess Jack's problem of "Low Back Pain"including the history and physical exam. The history of present illness(HPI) should include PQRST or OLDCART .

Answer 1

History:

onset of the event:

1. Jack complains of pain in the lower back since today.
2. He was lifting a sheet of plywood

Provocation:

1. The pain was most probably caused by the act of lifting a sheet of plywood.

Quality of the pain:

1. The lower back pain was sharp and continous.

Region and radiation:

1. The pain is located in the right back.
2. It radiates into the patient's leg

Severity:

1. On the numeric pain rating scale, the pain corresponded to a score of 10

Time:

1. The pain is acute in onset. Present only today.
2. He has had back injuries 3 times in the past 3 years. However, the pain due to these injuries has resolved with rest and medication ( muscle relaxants and Mortin). He was better within 3 days and was able to resume his work.

Physical examination:

1. Gait and posture
   • Observe the patient walk
   • Observe the posture of the patient
   • Postural abnormalities may be seen with scoliosis or muscle spasm
2. Range of Motion
   • The patient should be asked to bend
     • forward ( flexion)
     • bend backward( spine extension)
     • bending sideways (lateral flexion)
     • rotation of the spine
   • The pain on forward bending ( flexion) is usually seen with mechanical causes ( Muscle sprain, ligament sprain, facet disruption, intervertebral disc herniation)
   • Pain on back extension is suggestive of spinal stenosis
3. Palpation/percussion of the spine
   • This helps to pin-point the site of pain. A specific site of pain is usually seen with fracture.
4. Heel-toe walk
   • In this test, the patient is asked to walk in a straight line with a heel of one foot touching the toes.
   • If the patient has cauda equina syndrome (compression of the lower nerve roots) or cerebellar disease, the patient is unable to do so.
5. Squat and rise - The patient is unable to squat and rise if he has proximal muscle weakness, compression of the L3/4 and cauda equina.
6. Palpation of the sciatic notch
   • The sciatic notch is tender. On palpation, if the pain radiates to the leg it is suggestive of sciatica
7. Straight leg raising test
   • The patient is asked to lie supine on the bed.
   • The leg is raised passively
   • When the leg is at an angle of 30 degrees, the nerve becomes taut.
   • This causes pain.
   • In this position, if the leg is passively flexed at the knee the pain goes away.
8. Lasegue sign - When the leg is passive raised (30-degree angle with the bed), and the ankle is dorsiflexed - pain is felt. This is due to sciatica
9. Reflexes, motor, and sensory testing
   • the weakness of dorsiflexion of the great toe and ankle - suggestive of the weakness of the S1
   • Loss of sensation on the lateral side of the foot (S1)
   • Loss of sensation on the medial side of the foot (L4)
   • Loss of sensation on the dorsum of the foot ( L5)