By Day 6 of Week 8
Respond to at least two of your colleagues on 2 different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition and justify your reasoning.
Colleague 1 case study and response
Case 1: 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?
Colleague 1
Patient Information:
Name: J.J. Age: 42 Sex: Male Race: Caucasian
CC: Lower back pain
HPI: The patient is a 42-year-old Caucasian male who presents with a complaint of lower back pain over the last month. The patient describes the pain as stabbing or sharp. The pain is also associated with some numbness and tingling that radiates from his lower back, through his buttock then down to his left leg into his calf muscle. The patient reports the pain as “burning” at times. He reports the pain as 8/10 on a pain scale of 10. The patient’s pain worsens with activity, especially weight-bearing, extended standing, bending, twisting, or orthostasis. Quick movements also exacerbate the pain. The pain is intermittent in nature and unpredictable. The patient denies any further associated signs or symptoms. The patient takes over-the-counter pain medication which provides little relief. Rest, ice, and bathtub Epsom salt soaks also offer minimal to moderate relief. The patient believes the pain may be the result of lifting boxes and furniture while recently moving.
Current Medications:
Ibuprofen 600mg po PRN pain, approximately 15 times over the past month
Epsom Salt bath soaks PRN muscle ache/pain, dose per package guidelines
Allergies:
Sulfa-hives
No environmental, seasonal, or latex allergies
Medical Hx:
No major childhood illness or hospitalization
No major illness or hospitalizations
No history of sexually transmitted infections
No history of mental health disorders
Surgical:
Cholecystectomy 03/2010
Vaccines:
Childhood vaccines up to date
Tdap 06/2017
Flu vaccine 10/2022
Covid vaccine 09/2021; 11/2021
Social Hx:
The patient is happily married for 15 years to his wife Tanya. He has 1 child, Taylor who is 5 years old. He reports a satisfying family life with a supportive family and extended family. The patient owns his own home in a safe community, his home has working smoke detectors and carbon monoxide detectors. The client is a divorce attorney and denies environmental exposure at work. He reports mild amounts of stress at work and is satisfied with his career. J.J., before the chief complaint injury, had a routine exercise regimen of 4-5 days a week. The patient reports eating a well-balanced, health-conscious diet. He reports no financial concerns and has adequate access to healthcare services. The patient reports religious use of his seatbelt and does not use his cell phone while driving. J.J. reports annual visits with his primary care provider with the most recent visit approximately 4 months ago. The patient reports all routine lab work was within normal limits.
Alcohol use is rare, 2-3 times a year, usually during the holidays only, and 1-2 drinks per occurrence
Heterosexual relationship, he denies sexual dysfunction
Denies tobacco or illicit drug use
Denies recent travel
Family Hx:
Father: hypertension, age 68
Mother: healthy, age 67
Brother: hypertension, age 44
Maternal grandfather: colon cancer, deceased 63
Maternal grandmother: diabetes, 89
Paternal grandfather: deceased from MVA at age 55
Paternal grandmother: lung cancer, deceased 82
ROS:
GENERAL: Positive: pain associated with chief complaint. Negative: fatigue, weight loss, malaise, dizziness, lightheadedness, chills, fever, night sweats, or sleep disturbances
CARDIOVASCULAR: Negative: chest pressure or pain, edema, palpitations, arrhythmias, bradycardia, tachycardia, syncope, myocardial infarction.
RESPIRATORY: Negative: dyspnea, shortness of breath, orthopnea, cough or sputum, sleep apnea, pleuritic pain.
NEUROLOGICAL: Positive: paresthesia, dysesthesia. Negative: syncope, dizziness, paralysis, ataxia, changes in bladder or bowel control.
MUSCULOSKELETAL: Positive: pain and aching, decreased ROM. Negative: joint pain, tremor, tic, spasm, wasting, clumsiness.
INTEGUMENTARY: Negative: rash, bruising, discoloration, scars, pruritis or lesion
Objective Data:
Vital Signs: 122/76, 72, 99% RA, 16, 36.8C
Height: 6’2” Weight: 179 BMI: 23 (healthy)
Physical exam:
GENERAL: Alert, oriented x4, clear speech, well-appearing, calm, cooperative, and pleasant. No acute distress was noted. The patient has good hygiene and is well-groomed, he is dressed appropriately. He maintains eye contact throughout the interview and assessment. Independent gait with proper posture, antalgic gait noted.
CARDIOVASCULAR: s1 s2 audible, RRR with no friction rub, murmur, or gallop. No claudication or edema. Capillary refill <3 sec to all extremities. Palpated bilateral femoral pulse 3+ with no thrill. Palpated bilateral popliteal pulse, 3+ with no thrill. Palpated bilateral tibial pulse 3+ with no thrill. Palpated bilateral dorsalis pedis pulse 3+ with no thrill.
RESPIRATORY: Lung sounds present throughout all lung fields and clear. Breathing is unlabored with symmetrical chest rise and fall. Negative adventitious breath sounds.
NEUROLOGICAL: CN I-XII grossly intact. Bilateral patellar DTR’s 1+. Bilateral ankle reflexes 1+. Left leg positive for weakness on hip abduction and knee flexion. Left foot weak with dorsiflexion, toe extension, and flexion. Positive crossed straight leg test at 60 degrees. Positive Straight leg raise/Lasegue’s test on left leg at 45 degrees, negative on right leg. Positive femoral stretch test.
MUSCULOSKELETAL: Guarding and stiffness noted at lower back and left hip. Tenderness with gentle palpation to bilateral lumbar paraspinous region. Decreased lumbar ROM at 4cm with Schober test. Left leg weakness with knee flexion, hip adduction, and flexion. Pelvic, hip, and lumbar region with restricted ROM. Dermatomal sensory numbness absent. Spinal alignment with hips, knees, and ankles on same horizontal plane. Kyphosis, lordosis, and scoliosis are absent. Equal bilateral lower extremity circumference.
INTEGUMENTARY: Warm, dry, pink, and intact. Appropriate for race. No redness, cyanosis, dryness, scarring, lesions, rashes, bruising, petechiae, cyst, protrusion, birthmark, or discoloration noted.
Diagnostic results:
Completed with assessments: Schober test, Crossed straight leg test, Laseque’s test, and femoral stretch test
FAIR (flexion, adduction, and internal rotation) test: Can provide additional assessment data and finding to help with strengthening and supporting a diagnosis such as piriformis syndrome. Evaluates the impact of the piriformis muscle on the sciatic nerve (Physiopedia, 2022).
MRI: computer-generated imaging of soft and bony structures, tendons, ligaments, and blood vessels.
EMG: used to diagnose piriformis syndrome by observation of H waves (Hicks et al., 2017). Assesses the muscle’s electrical activity, detecting weakness within the muscle.
CT myelography: offers enhanced imaging of CT scans and X-rays. Contrast dye is utilized during the study and enhances traditional imaging.
CT scan: The preferred imaging study to visualize the bony structures of the spine (Alves et al., 2021). Can also show soft tissue structures that cannon be seen by conventional X-rays.
X-ray: Inexpensive and accessible. Can determine structural instability (Alves et al., 2021).
Discography: Contrast dye placed into the spinal disc in the region thought to be the cause of discomfort. Fluid pressure within the disc will replicate the patient’s symptoms if the disc is the cause of pain (National Institute of Neurological Disorders and Stroke, 2021).
Nerve conduction studies (NCS): Use of electrodes to stimulate the nerve that runs adjacent to a specific muscle recording the nerve signals.
Differential Diagnoses
L2, L3, and/or L4 disc herniation: L2, L3, and L4 herniated disc often present with back pain that radiates into the medial lower leg and anterior thigh with occasional sensory loss in the same regions (Alves et al., 2021). Common findings in solitary nerve lesion due to compression are created by a herniated disk within the lumbar spine (Alves et al., 2021). Hip flexion, adduction weakness, weakened knee extension, and diminished patellar reflex are common findings with these levels of lumbar spine disc herniation (Alves et al., 2021).
Sciatic radiculopathy secondary to lumbar disc herniation: Numerous etiologies for lower back pain exist. Radicular pain alongside the sciatic nerve root is the revealing indication that lumbosacral nerve compression, disc herniation, or degenerative disc disease is the causative pathology (Wang et al., 2019).
Piriformis Syndrome: Diagnosing the differences between piriformis syndrome and disc herniation can be challenging for practitioners. Branches of the L5, S1, and S2 innervate the piriformis muscle causing symptoms similar to that of a herniated disc (Carro et al., 2016). Common causes of piriformis syndrome are muscle hypertrophy, sitting for prolonged periods, anatomic anomalies, or trauma to the buttock or hip region (Hicks et al., 2017). Likely presentations of piriformis syndrome include pain when getting out of bed, inability to sit for extended periods of time, pain in the buttocks which worsens with hip movements, and chronic pain in the hip and buttocks region (Hicks et al., 2017).
Spinal Stenosis: Spinal stenosis causes narrowing in your spine, this narrowing creates pressures on your nerves and spinal cord and can result in pain (National Library of Medicine, 2022). Spinal stenosis is more common in individuals who are 50 years and older (National Library of Medicine, 2022). Common symptoms of spinal stenosis include numbness, weakness, cramping or pain in the arms and legs, pain in the neck or back, pain going down the leg, and foot problems (National Library of Medicine, 2022). Lumbar spinal stenosis can make legs feel tired, weak, or cramped and commonly starts with standing or walking. (American Academy of Family Physicians, 2022). Leaning over or climbing up stairs can improve the patient’s symptoms while walking down the stairs causes a worsening of pain; common causes are falls, accidents, arthritis, and wear and tear on joints and bones (American Academy of Family Physicians, 2022).
Spondylosis: Spondylosis is the generalized degeneration of the spine that occurs naturally with normal wear and tear of the discs, joints, and bones as people age (National Institute of Neurological Disorders and Stroke, 2021). Spondylosis is quite common and typically worsens with age. The major risk factor in having Spondylosis is age, most individuals 60 and over have signs of spondylosis on imaging. Pain and spasm is a common symptom of
spondylosis.
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By the sixth day of Week 8,
On two separate days, respond to at least two of your colleagues who were given different case studies than you. Examine the illnesses that your colleagues’ differential diagnoses could indicate. Decide which of the conditions you’d refuse and why. Determine the most likely scenario and explain your reasoning.
Case study and reaction from Colleague 1
Back Pain in the First Case
For the past month, a 42-year-old man has been experiencing pain in his lower back. His left leg is occasionally affected by the ache. What nerve roots might be involved in establishing the origin of back discomfort based on your anatomical knowledge? What methods would you use to test for each of them? What other symptoms need to be explored? What are your differential diagnoses
