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Asked by ColonelField1376

A 55 year old male comes to your office for complaints of lower back pain.  He tells you he is in terrible pain and could barely get out of bed for the past three days, which was why he made the appointment.  He describes the pain as aching, in the lower portion of his back.  Worse in the AM upon rising and then more tolerable with mild activity.  The pain is worse again when sitting for long periods.  He rates the pain as 10/10 when it is at its worst.  At various times when it is more tolerable, it is closer to a 6.  He says he has taking anything he can find in his medicine cabinet but “nothing helps.”  He has taken ibuprofen and Tylenol.  His friend gave him some naproxen but that did not help either.

He works in finance and spends most of his day at a desk.  He walks from the train to the office, a 20 minute walk, every workday so he considers himself to exercise regularly.

You ask many questions to determine when the back pain started and what could have caused it.  The pain started about a week ago and it may have been caused/aggravated when babysitting his grandchild because he was carrying him around a lot.

 

List 5 questions you would ask this patient to determine the seriousness of this injury.  For each question, explain why you would ask this and what this means for your medical decision-making.
Describe your physical exam for this patient.    What would you be looking for and explain how your exam findings would influence your diagnosis.
What labs/diagnostics would you order for this patient and why?  If you need more information to determine a specific test, indicate the test, what exam findings would lead you to order it and why.
Let’s assume this patient has no neurological symptoms associate with the back pain and you do not feel this pain represents any critical injury.  What would be your plan of care for this patient?  List 5 items to include in your plan of care, include the evidence to support your points.  If PT is or is not indicated, please explain why according to the guidelines.
Use recent references in your answers

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
NU 639

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