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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?
Patient Information: C.B., 42-year-old Caucasian male
SUBJECTIVE DATA:
Chief Complaint (CC): Patient reports pain in his lower back for the past month. Patient states,
“The pain sometimes radiates to my left leg.”
History of Present Illness (HPI): The patient is a 42-year-old Caucasian male who presents to
the clinic with having pain in his lower back for the past month. He states, “The pain sometimes
radiates to my left leg.” He reports the worst pain being a 10 out of 10 when trying to lift
something heavy or bending down. He is relieved by sitting on his recliner where his pain
lessens to a 4 out of 1 to 10 pain scale or when laying down.
1. Location – lower back
2. Quality – tigh, sharp and uncomfortable.
3. Quantity or severity – 10/10 at its worst, 04/10 at this moment.
4. Timing, including onset, duration, and frequency – onset a month ago,
lasting continously, with intermittent relief.
, 2
5. Setting in which it occurs – During lifting and bending at home and walking
at work.
6. Factors that have aggravated or relieved the symptom – Pain relieved by
lying down, aggravated with physical activity.
7. Associated manifestations – When lifting anything and walking.
Medications:
Multi-vitamins
Tylenol and Ibuprofen as needed for pain every 4 to 6 hours.
Allergies: Demerol – causes nausea and vomiting and severe itching. Denies food
or environmental allergies.
Past Medical History (PMH): No significant past medical history.
Past Surgical History (PSH): Ear tubes at age 2. Laprascopic appendectomy at age 7.
No recent hospitalization.
Sexual/Reproductive History: One sexual partner for the last 15 years married to his
wife with two children ages 10 and 12.
Personal/Social History:
Patient is an accountant for a law firm
Married for 15 years to the same partner
Patient has two children 10 yr old son and a 12-year-old daughter
Reports having a primary care provider – last visit 6 months ago.
Patient denies tobacco use, marijuana, cocaine, heroin or other illicit drugs.
Drinks 1 to 2 beers on a weekend.
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?
Patient Information: C.B., 42-year-old Caucasian male
SUBJECTIVE DATA:
Chief Complaint (CC): Patient reports pain in his lower back for the past month. Patient states,
“The pain sometimes radiates to my left leg.”
History of Present Illness (HPI): The patient is a 42-year-old Caucasian male who presents to
the clinic with having pain in his lower back for the past month. He states, “The pain sometimes
radiates to my left leg.” He reports the worst pain being a 10 out of 10 when trying to lift
something heavy or bending down. He is relieved by sitting on his recliner where his pain
lessens to a 4 out of 1 to 10 pain scale or when laying down.
1. Location – lower back
2. Quality – tigh, sharp and uncomfortable.
3. Quantity or severity – 10/10 at its worst, 04/10 at this moment.
4. Timing, including onset, duration, and frequency – onset a month ago,
lasting continously, with intermittent relief.
, 2
5. Setting in which it occurs – During lifting and bending at home and walking
at work.
6. Factors that have aggravated or relieved the symptom – Pain relieved by
lying down, aggravated with physical activity.
7. Associated manifestations – When lifting anything and walking.
Medications:
Multi-vitamins
Tylenol and Ibuprofen as needed for pain every 4 to 6 hours.
Allergies: Demerol – causes nausea and vomiting and severe itching. Denies food
or environmental allergies.
Past Medical History (PMH): No significant past medical history.
Past Surgical History (PSH): Ear tubes at age 2. Laprascopic appendectomy at age 7.
No recent hospitalization.
Sexual/Reproductive History: One sexual partner for the last 15 years married to his
wife with two children ages 10 and 12.
Personal/Social History:
Patient is an accountant for a law firm
Married for 15 years to the same partner
Patient has two children 10 yr old son and a 12-year-old daughter
Reports having a primary care provider – last visit 6 months ago.
Patient denies tobacco use, marijuana, cocaine, heroin or other illicit drugs.
Drinks 1 to 2 beers on a weekend.
