lower back pain
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Initials: J.S Age: 42 Sex: Male Race: African American
S.
CC: “I am experiencing lower back pain that radiates to my left leg”
HPI: Mr. Smith is a 42-year-old African American male who reports to the clinic complaining of lower back pain that periodically radiates to his left leg. The pain started about one month ago. The character of the pain is shooting and stabbing. It appears to get worse when sitting for an extended period of time, bending over and during strenuous physical activity. The severity of the pain is 8/10 without medications but relieves to about 3/10 after taking Tylenol and getting some rest.
Location: Lower back
Onset: 1 month
Character: Shooting and Stabbing
Associated signs and symptoms: nausea, vomiting, photophobia.
Timing: Sitting for extended periods, bending over and strenuous physical activity.
Exacerbating/ relieving factors: Tylenol and rest makes the pain tolerable, but not completely better.
Severity: 8/10 pain scale
Current Medications:
Metoprolol 100 mg tablet, PO once daily.
Acetaminophen 500 mg tabs, 1-2 PO q 6 hrs, PRN for pain. (not to exceed 3 g in 24 hr).
PMHx:
Diagnosis: Hypertension
Surgical Hx: Laparotomy, 02/2000
Immunizations: Childhood immunizations completed. Tetanus and Flu shots are up-to-date.
Soc Hx: Unemployed. Lives alone and never married. Has one brother and both parents are alive. Performs physical exercise regularly at the gym, and uses seat belts all the time when driving. Denies tobacco and alcohol use.
Fam Hx: Father has a stroke and heart disease, Mother has hypertension, Brother has diabetes. Maternal and Paternal grandparents died of a stroke 2 years ago.
ROS: BP – 140/90 L arm, P – 86, T – 98.1 oral, RR – 18, Ht. – 5’10”, Wt. – 200 lbs. BMI 28.7
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, doubles vision or yellow sclerae.
Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
Skin: No rash or itching. No skin lesions or moles that are new or suspicious.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. No pleurisy pain, no hx of a heart murmur. No EKG on record. No peripheral edema or claudication. BP controlled with medication.
RESPIRATORY: No cough, sputum or SOB. No DOE, hemoptysis. Chest X-rays – 3 years ago.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. No unintentional weight loss or gain. No change in bowel habits.
GENITOURINARY: No penile discharge or erectile dysfunction. No nocturia, dribbling, or incontinence.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. No reports of numbness or tingling to the left leg since the onset of lower back pain.
MUSCULOSKELETAL: Reports lower back pain that sometimes radiate to the left leg. No edema noted.
HEMATOLOGIC: No hx of Blood transfusions. No anemia, bleeding or bruising.
LYMPHATICS: No hx of splenectomy. No enlarged lymph nodes.
PSYCHIATRIC: No hx of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. No heat or cold intolerance.
ALLERGIES: NKFA, NKDA
O.
Physical exam:
General: Alert & Oriented x3. Appears well-nourished but exhibits a slight limp due to left leg pain.
Cardiovascular: Regular heart rate and rhythm, normal heart sounds and intact pulses. No murmurs, gallops or pericardial friction rub.
Pulm/chest: No respiratory distress. Lung Sounds clear to auscultation in all fields.
Abdomen: Soft, non-tender, Bowel sounds present x4 quadrants.
Musculoskeletal: Decreased mobility with lower back pain. Limited ROM with lumbar flexion. Gait disturbances, leaning to the right side on examination. Muscle spasms noted.
Hip flexion/ extension and strength against resistance indicates weakness to left gluteus maximus and L5 nerve root involvement. No hip or joint instability, knees equal in height
Neurological: Bilateral L3-S1 dermatomes reactive to touch, no decrease in sensation. Deep tendon reflexes are symmetrical. Knee jerk reflex positive and symmetrical bilaterally.
Diagnostic results:
Urinalysis: Negative, Light-yellow urine.
