NURSING GR 6512 / Back Pain Case for Week 8 Focused Note

NURSING GR 6512 / Back Pain Case for Week 8 Focused Note 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: M.S. Age 42 Caucasian Male S. CC: “Lower Back Pain” HPI: The patient is a 42-year-old white male who developed lower back pain for 1 month. He states the pain radiates to his left leg. His lower back pain is increased with sitting for long periods of time, states the pain gets better when stands. Denies any fever, chills, and sweating. Current Medications: Omeprazole 20 mg daily, Atorvastatin 40 mg daily, Motrin 200 mg two every 4 to 6 hours as needed for pain Allergies: No known drug, food, or environmental allergies. PMHx: GERD, Hypercholesterolemia PSHx: Adenoidectomy 1975 Soc Hx: M.S. is a retired plumber who lives alone. He enjoys activity such as walking, bike riding and camping outdoors. Personal/Social History: Patient denies ever smoking cigarette. Denies any recreational drug use. Fam Hx: Mother alive, age 72-years-old, breast cancer at age 52 in remission. Father died at age 70 (2yrs ago) – history of CAD, MI age 70 died. ROS: GENERAL: No weight loss. Complaint of lower back pain. No complaint of fever, chills, weakness, fatigue, constipation, bladder or bowel incontinent. HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.