Assignment: 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.   42-year-old White Male S. Chief Complaint: “low back pain for the past month that sometimes radiates to my left leg.” HPI: The patient is a 42-year-old white male who is complaining of low back pain that began one month ago.  He explains that the pain will intermittently radiate to his left leg as well.  He reports that the pain is constant and is also “sharp” at times.  He describes the pain that radiates to his left leg as a “tingling” sensation and can sometimes even feel it “all the way down to his toes.”  He rates the pain at an “8” when he is standing or walking but describes that the intensity decreases to a “4” when he is sitting or lying down.  The patient complains of intermittent numbness and tingling in his left leg that seems to have gotten worse “in the past week.”  He explains that the numbness and tingling is always worse first thing in the morning.  He also describes the pain as almost “unbearable” after working a 12-hour shift and that he even has experienced a loss of appetite on those days after working long hours.  He explains that the pain does wake him up sometimes at night. The patient explains that Aleve has been his “lifesaver,” as he does not feel that he could have worked at all if it wasn’t for taking it routinely before work.  He proceeded to verbalize that the Aleve only “took the edge off,” but that he is worried about the effect it may be having on his stomach.     Current Medications:  Centrum Vitamin for Men, one PO daily; Aleve capsule, one PO every 8 hours; over-the-counter Zantac 150 mg PO, “occasionally” at bedtime for heartburn. Allergies:  PCN- experienced hives after taking as a teenager; Denies food or environmental allergies. PMH:  Occasional acid reflux, history of childhood asthma, hospitalized last year with pneumonia.  Reports only surgery being tonsillectomy at age 5.  Reports that he is current with immunizations and received a tetanus injection two years ago when he cut his finger at work.  FH:  Father died at age 60 with a heart attack, mother is living and has HTN.  Maternal grandparents are living with no history of heart disease or cancer.  Maternal grandmother-type 2 diabetes; Maternal grandfather- HTN, controlled with medication.  Paternal grandmother- living and in excellent health, with no history of heart disease or cancer. Paternal grandfather died at age 72 with a heart attack.  Reports that both children are in excellent health.  Denies a history of back pain or scoliosis with maternal or paternal relatives. SH:  Works as a nurse in the ICU at a local hospital and has been married for 15 years; they have two school-aged children.  He reports that he and his family love to spend time outdoors and that they usually hike on the weekends together..

1. Assignment:
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.
42-year-old White Male
S.
Chief Complaint:
“low back pain for the past month that sometimes radiates to
my left leg.”
HPI:
The patient is a 42-year-old white male who is complaining of
low back pain that began one month ago. He explains that the
pain will intermittently radiate to his left leg as well. He
reports that the pain is constant and is also “sharp” at times. He
describes the pain that radiates to his left leg as a “tingling”
sensation and can sometimes even feel it “all the way down to
his toes.” He rates the pain at an “8” when he is standing or
walking but describes that the intensity decreases to a “4” when
he is sitting or lying down. The patient complains of
intermittent numbness and tingling in his left leg that seems to
have gotten worse “in the past week.” He explains that the

2. numbness and tingling is always worse first thing in the
morning. He also describes the pain as almost “unbearable”
after working a 12-hour shift and that he even has experienced a
loss of appetite on those days after working long hours. He
explains that the pain does wake him up sometimes at night. The
patient explains that Aleve has been his “lifesaver,” as he does
not feel that he could have worked at all if it wasn’t for taking
it routinely before work. He proceeded to verbalize that the
Aleve only “took the edge off,” but that he is worried about the
effect it may be having on his stomach.
Current Medications:
Centrum Vitamin for Men, one PO daily; Aleve capsule, one
PO every 8 hours; over-the-counter Zantac 150 mg PO,
“occasionally” at bedtime for heartburn.
Allergies:
PCN- experienced hives after taking as a teenager; Denies food
or environmental allergies.
PMH:
Occasional acid reflux, history of childhood asthma,
hospitalized last year with pneumonia. Reports only surgery
being tonsillectomy at age 5. Reports that he is current with
immunizations and received a tetanus injection two years ago
when he cut his finger at work.
FH:
Father died at age 60 with a heart attack, mother is living and
has HTN. Maternal grandparents are living with no history of
heart disease or cancer. Maternal grandmother-type 2 diabetes;
Maternal grandfather- HTN, controlled with medication.
Paternal grandmother- living and in excellent health, with no
history of heart disease or cancer. Paternal grandfather died at
age 72 with a heart attack. Reports that both children are in
excellent health. Denies a history of back pain or scoliosis with

3. maternal or paternal relatives.
SH:
Works as a nurse in the ICU at a local hospital and has been
married for 15 years; they have two school-aged children. He
reports that he and his family love to spend time outdoors and
that they usually hike on the weekends together. He explains
that he is very active in his local church and teaches a class
there on Wednesday nights. He denies any past tobacco use,
including smokeless tobacco. He also denies any history of
illicit drug use. The patient explains that he drank beer on the
weekends in college but denies alcohol use at this time. He
reports that his family lives in the country, but states that he
and his wife’s family only live one hour away and are all very
supportive. The patient reports regular use of a seat belt and
was reminded of the danger of texting and driving, as he
admitted that this is something that he is in the habit of doing.
ROS:
General:
Reports 7 lb. weight loss in the past month; Denies fevers or
chills. Reports increased fatigue due to pain waking him up at
night. Reports increased anxiety that he relates to the constant
pain.
Skin:
Negative for rash, lesions, cysts, or wounds
.
Cardiovascular:
Negative for chest pain, tightness, or chest pressure. Negative
for palpitations. Denies any issues with swelling in extremities.
Respiratory:

4. Negative for shortness of breath, cough, or sputum. Denies
shortness of breath even after long hikes.
Gastrointestinal:
Negative for abdominal pain. Reports some nausea when back
pain is intensified but denies vomiting. Reports normal bowel
movements with no issues of diarrhea, constipation, or blood in
stools. Positive for heartburn for at least the past couple of
years, especially at night. Negative for bowel incontinence.
Genitourinary:
Negative for burning upon urination or frequency. Negative
for urinary incontinence.
Neurological:
Negative for headaches, dizziness, or fainting. Denies head
trauma. Positive for intermittent numbness and tingling in left
leg, foot, and toes. Denies numbness or tingling in any other
extremities. Denies any problems with balance or coordination.
Musculoskeletal:
Denies muscle weakness. Positive for constant low back pain.
Positive for back and left leg stiffness upon getting up in the
mornings. Denies any other joint pain or issues.
Hematologic:
Negative for a history of bleeding problems. Denies any back
trauma, wounds, or lesions. Denies any unusual bruising.
Lymphatics:
Negative for any swollen lymph nodes.
Psychiatric:
Reports no history of depression or mental disorders. Admits
to current anxiety that he relates to constant back pain.

5. O.
Vital signs:
B/P 135/72; Pulse 83; RR 18; O2 Sat 98%; Temp. 98.3; Wt.
205 lbs.; Ht. 72”
General:
Patient sitting on edge of the exam table, appears restless and
anxious. He is alert and oriented x3 and responds appropriately
to all questions.
Skin:
Warm, dry, and intact. No evidence of rashes, lesions, wounds,
or cysts. Adequate turgor.
Respiratory:
Breath sounds clear and equal upon auscultation in all 4 lobes
anteriorly and posteriorly. No adventitious sounds heard.
Symmetrical chest wall expansion noted. No difficulty in
breathing patterns noted.
CV:
Heart RRR, no audible murmurs or gallops. No peripheral
edema noted. Tibial and dorsalis pedal pulses present, 2+
bilaterally
.
Capillary refill less than 3 seconds in fingers and toes
bilaterally
,
with no cyanosis noted.
Abdomen:
Soft and nontender. No distention; no palpable masses. Bowel
sounds normoactive in all 4 quadrants. No evidence of
guarding. No flank tenderness noted bilaterally.

6. Rectal:
No prostate tenderness or enlargement noted upon palpation.
Back:
Spine straight with no obvious curvature. Full ROM of the
spine, but tenderness reported upon palpation of the sacroiliac
region
.
Musculoskeletal:
full weight-bearing. No evidence of gait disturbances. Full
ROM noted in all 4 extremities. Leg measurements are equal.
Positive FABER test upon placing the left leg on right knee,
pain reported in the sacroiliac region. Straight leg raises
performed bilaterally, with complaints of pain verbalized upon
45 degrees of elevation. Pain in the sacroiliac region also
voiced upon left ankle dorsiflexion
(
Dains, Baumann, & Scheibel, 2019, Chapter 24
).
Neurological:
Alert and oriented x 3; appropriate mood and affect in the
present circumstance of constant pain. No foot drop noted when
examined bilaterally (Dains et al., 2019). Reflexes are 2+ and
equal bilaterally, including deep tendon (Dains et al., 2019).
Strength is 5/5 in all extremities except for left leg, which is
assessed at 4/5 (Sullivan, 2019, Chapter 2). No evidence of
limping with ambulation.
Diagnostic Results:
CBC:
WBC 14, 500; HgB 12.3; Hct 46%. While this patient’s WBC
is only slightly elevated, it is important to consider the presence

7. of an infection in the back or spinous processes. While he has
not reported any fever or chills, clinicians can never be too
certain that there is not a hidden bacterium that would be the
causative agent for the reported symptoms (Dains et al., 2019).
Additionally, as the thought of a malignant condition is always
in the minds of patients and clinicians, alike, it is essential to
assess the H & H of the individual (Dains et al., 2019). While
anemia is commonly present amongst cancer diagnoses, ranging
anywhere from 30% to 90% of diagnosed patients, the extent of
such a condition will vary according to the type of tumor
(Krasteva, Harari, & Kalsi, 2019).
UA:
negative for blood, nitrites, or bacteria. As the advanced
practice nurse, it is equally important to ensure that there is no
specific visceral involvement, such as what can occur with the
kidneys when there is infection present (Dains et al., 2019).
The U/A results would be helpful information to rule out a
condition known as pyelonephritis (Dains et al., 2019).
ESR:
25 mm/hr
.
A hematologic test, known as an erythrocyte sedimentation
rate, is very useful when trying to conclude if infection,
inflammation, trauma, or even malignant disease is present
(Patil, Muduthan, & Kunder, 2019). While the ESR can be
initially elevated in the acute stages of an illness, it is a
significant enough diagnostic test to perform when trying to
rule out infection as the underlying cause of the condition (Patil
et al., 2019).
PSA:
9.2. The elevated PSA level in this gentleman does warrant
enough suspicion for the advanced practice nurse, as there is
always a potential for prostate cancer with bony metastasis in

8. the spinal region (Bakhsh et al., n.d.). The bony lesions that are
found in metastatic prostate cancer are typically osteoblastic in
nature (Bakhsh et al., n.d.).
MRI:
awaiting the radiologist report. The condition of the soft tissue
in the spinal region is best visualized with magnetic resonance
imaging (Dains et al., 2019). There are medical conditions that
need to be ruled out as a source of the back pain, such as disc
herniations, tumors, and various diagnoses that originate from
the spinal cord (Dains et al., 2019).
A.
1.) Sciatica:
While it is vital that other medical conditions that originate
from the spine are reviewed, sciatica is a presumptive diagnosis
for this male patient that is experiencing low back pain. The
long-standing nursing career of this male patient often involves
a great deal of twisting, bending, and lifting that has become
repetitive (Dains et al., 2019). The bowel and bladder functions
are not usually compromised, but the patient will experience a
significant amount of pain, burning, and even numb sensations
in the buttock and leg of the affected side (Dains et al., 2019).
The straight leg raises test (SLR) will usually reveal positive
results, which was the case of this male patient (Dains et al.,
2019).
2.) Primary or metastatic tumor:
The advanced practice nurse must rule out the presence of a
tumor type, first and foremost, before proceeding on to other
differential diagnoses. While this patient may not have all the
“classic” indicators of malignancy, it is vital that clinicians
understand that no one patient will present with a malignant
condition in the same exact fashion. The elevated PSA in this
young 42-year-old male is enough indication to ensure that a

9. malignant condition is not the underlying cause for his
symptomology. The weight loss that the patient has reported is
a symptom that does require further exploration.
3.) Disc Herniation:
Although numbness and tingling are not as common with a disc
herniation, patients with such a condition will usually complain
of pain that radiates throughout the leg of the affected side
(Dains et al., 2019). The patient with a herniated disc will quite
frequently have positive straight leg tests, and an MRI is
undoubtedly warranted if the patient has experienced back pain
for at least one month (Dains et al., 2019).
4.) Infection:
A condition known as osteomyelitis can often occur in the
spine, especially if the patient has experienced recent infection
in a neighboring anatomical region or if they have undergone a
type of invasive procedure where various instrumentation was
utilized (Dains et al., 2019). Sadly enough, infection ranks high
in the medical community as one of the most overlooked
conditions by well-intended clinicians (Mohamed, Finucane, &
Selfe, 2019). The cause for many of these errors that pertain to
spinal infections is because of the extended period between the
time of initial onset to the time of full development of the
condition (Mohamed et al., 2019). The consideration of
infection is very prudent with this male patient, as his slight
WBC elevation and ESR level do require further exploration.
5.) Spinal Stenosis:
While this condition is typically diagnosed in those patients
over 50 years of age, the advanced practice nurse must take into
consideration the length of time that this male patient has
endured long hours on his feet in his nursing career. Spinal
stenosis of the lumbar region is a common location and is
usually associated with degenerative changes of the three-joint
complex (Abbas, Peled, Hershkovitz, & Hamoud, 2019). The

10. presence of neurogenic claudication is an anticipated clinical
symptom, with pain levels increasing upon long periods of
standing (Abbas et al., 2019). The pain will normally radiate to
one or both buttocks, legs, and feet
(
Abbas et al., 2019).