this dq is due for tomorrow 08/18/18 You are working with Dr. Lee today. She hands you a triage note from the nurse regarding your next patient, Mr. Payne: Forty-five-year-old white male truck driver complaining of two weeks of sharp, stabbing back pain. The pain was better after a couple of days but then got worse after playing softball with his daughter. This morning his pain is so bad that he had trouble getting out of bed. Dr. Lee provides you some background information about low back pain. TEACHING POINT Low Back Pain Prevalence, Cost, & Duration Low back pain (LBP) is the fifth most common reason for all doctor visits. In the U.S., lifetime prevalence of LBP is 60% to 80%. The direct and indirect costs for treatment of LBP are estimated to be $100 billion annually. Fortunately, most LBP resolves in two to four weeks. Dr. Lee continues: "There are many causes for LBP. For presenting symptoms that have a broad differential diagnosis, I find it helpful to think of systems of etiologies in which diseases or conditions can be categorized." TEACHING POINT Common Causes of Back Pain Musculoskeletal (MSK) and Non-MSK Causes of Back Pain MSK Causes Axial: Degenerative disc disease Facet arthritis Sacroiliitis Ankylosing spondylitis Discitis Paraspinal muscular issues SI dysfunction Radicular: Disc prolapse Spinal stenosis Trauma: Lumbar strain Compression fracture Non-MSK Causes Neoplastic: Lymphoma/leukemia Metastatic disease Multiple myeloma Osteosarcoma Inflammatory: Rheumatoid Arthritis Visceral: Endometriosis Prostatitis Renal lithiasis Infection: Discitis Herpes zoster Osteomyelitis Pyelonephritis Spinal or epidural abscess Vascular: Aortic aneurysm Endocrine: Hyperparathyroidism Osteomalacia Osteoporosis Paget disease Dr. Lee suggests, "Now, let's look a bit more at the risk factors for mechanical low back pain that you can review with Mr. Payne during your history." Dr. Lee continues, "The major task in treating back pain is to Now that you have a diagnosis of disc herniation with radiculopathy for Mr. Payne, let's discuss what would you like to do for him distinguish the common causes for back pain (95% of cases) from the 5% with serious underlying diseases or neurologic impairments that are potentially treatable." TEACHING POINT Risk Factors for Low Back Pain Prolonged sitting, with truck driving having the highest rate of LBP, followed by desk jobs Deconditioning Sub-optimal lifting and carrying habits Repetitive bending and lifting Spondylolysis, disc-space narrowing, spinal instability, and spina bifida occulta Obesity Education status: low education is associated with prolonged illness Psycho-social factors: anxiety, depression stressors in life Occupation: Job dissatisfaction, increased manual demands, and compensation claims TEACHING POINT Red Flags For Serious Illness or Neurologic Impairment with Back Pain Fever Unexplained weight loss ...

1. this dq is due for tomorrow 08/18/18
You are working with Dr. Lee today. She hands you a triage
note from the nurse regarding your next patient, Mr. Payne:
Forty-five-year-old white male truck driver complaining of two
weeks of sharp, stabbing back pain. The pain was better after a
couple of days but then got worse after playing softball with his
daughter. This morning his pain is so bad that he had trouble
getting out of bed.
Dr. Lee provides you some background information about low
back pain.
TEACHING POINT
Low Back Pain Prevalence, Cost, & Duration
Low back pain (LBP) is the fifth most common reason for all
doctor visits. In the U.S., lifetime prevalence of LBP is 60% to
80%. The direct and indirect costs for treatment of LBP are
estimated to be $100 billion annually. Fortunately, most LBP
resolves in two to four weeks.
Dr. Lee continues: "There are many causes for LBP. For
presenting symptoms that have a broad differential diagnosis, I
find it helpful to think of systems of etiologies in which
diseases or conditions can be categorized."
TEACHING POINT

2. Common Causes of Back Pain
Musculoskeletal (MSK) and Non-MSK Causes of Back Pain
MSK Causes
Axial:
Degenerative disc disease
Facet arthritis
Sacroiliitis
Ankylosing spondylitis
Discitis
Paraspinal muscular issues
SI dysfunction
Radicular:
Disc prolapse
Spinal stenosis
Trauma:
Lumbar strain

3. Compression fracture
Non-MSK Causes
Neoplastic:
Lymphoma/leukemia
Metastatic disease
Multiple myeloma
Osteosarcoma
Inflammatory:
Rheumatoid Arthritis
Visceral:
Endometriosis
Prostatitis
Renal lithiasis
Infection:

4. Discitis
Herpes zoster
Osteomyelitis
Pyelonephritis
Spinal or epidural abscess
Vascular:
Aortic aneurysm
Endocrine:
Hyperparathyroidism
Osteomalacia
Osteoporosis
Paget disease
Dr. Lee suggests, "Now, let's look a bit more at the risk factors
for mechanical low back pain that you can review with Mr.
Payne during your history."
Dr. Lee continues, "The major task in treating back pain is to
Now that you have a diagnosis of disc herniation with

5. radiculopathy for Mr. Payne, let's discuss what would you like
to do for him distinguish the common causes for back pain (95%
of cases) from the 5% with serious underlying diseases or
neurologic impairments that are potentially treatable."
TEACHING POINT
Risk Factors for Low Back Pain
Prolonged sitting, with truck driving having the highest rate of
LBP, followed by desk jobs
Deconditioning
Sub-optimal lifting and carrying habits
Repetitive bending and lifting
Spondylolysis, disc-space narrowing, spinal instability, and
spina bifida occulta
Obesity
Education status: low education is associated with prolonged
illness
Psycho-social factors: anxiety, depression stressors in life
Occupation: Job dissatisfaction, increased manual demands, and
compensation claims
TEACHING POINT
Red Flags For Serious Illness or Neurologic Impairment with

6. Back Pain
Fever
Unexplained weight loss
Pain at night
Bowel or bladder incontinence
Neurologic symptoms
Saddle anesthesia
HISTORY
You and Dr. Lee take a few minutes to review Mr. Payne's
chart:
Vital signs:
Temperature:
98.6° Fahrenheit
Heart rate:
80 beats/minute
Respiratory rate:
12 breaths/minute
Blood pressure:
130/82 mmHg

7. Weight:
170 pounds
Body Mass Index:
24 kg/m2
Past Medical History:
Diabetes, well controlled. Hypertension, fair control.
Hyperlipidemia, fair control.
Past Surgical History:
None
Social History:
Works as a truck driver, which involves lifting 20-35 lbs 4
hours of the day, married with 2 daughters,
Habits:
Quit smoking two years ago, drinks 1 to 2 beers occasionally
on the weekends, no history of IV drug use.
Medication:
metformin 500mg 2 twice daily
glyburide 5mg 2 twice daily
amlodipine 2.5 mg daily
lisinopril 40 mg daily
simavastin 40 mg daily

8. Allergies
: No known drug allergies
After introducing yourself to Mr. Payne, you sit down across
from him and begin your history, focusing on the key elements.
"Can you tell me about your back pain?"
"As I told the nurse, the pain started two weeks ago after I
lifted a box at work. Right away, I got this sharp pain on the
left side of my back. The box wasn't even that heavy.
"I talked to the nurse at work; she said to ice it and to take
ibuprofen. It got better after three days. But, I was playing
softball with my daughter last weekend, and the pain came back.
This time it was worse than before. This week, the pain is so
bad I can hardly get out of bed. I get a sharp pain in my back
which goes down my left leg to my ankle."
"On a scale of 0 to 10, 10 being the worst, how severe is the
pain?"
"It's probably a 7."
"Have you found anything that improves the pain?"
"Ibuprofen and Naproxen worked at first, but they are not
helping much anymore."
"What about positions that make things better or worse?"
"The pain is worse with any movement of my back or sitting for
a long time. It is better when I lie down."
"Have you had back pain before?"

9. "Yes, I have back pain from time to time. But I'm usually better
after 2 to 3 days. This is the worst pain I have ever had."
You complete your history with a review of systems and
discover:
Review of Systems
Mr. Payne does not have numbness or weakness in his legs. The
pain is better when he lies down. He denies urinary frequency,
dysuria, problems with bowel or bladder control, fever or chills,
nausea or vomiting, or weight loss. He denies any specific
trauma, except for when he lifted a 10-pound box at work. He
denies unrelenting night pain.
You excuse yourself from Mr. Payne to discuss your findings
with Dr. Lee.
Dr. Lee walks through the steps for completing a neurologic
exam in a patient with back pain.
Back Exam - Standing:
Mr. Payne has normal curvature, tenderness on palpation on the
left lumbar paraspinous muscle with increase tone. Full range of
motion, but has pain with movement. His gait is normal. He can
walk on his heels and toes. He can do deep knee bends.
Back Exam - Seated:
Mr. Payne denies feeling pain when checked for CVA
tenderness. He has no pain in his right leg with the modified
version of SLR. While he does not exhibit a true tripod sign, he
does complain of pain when his left leg is raised. Mr. Payne's
reflexes are 2+ and equal at the knees and 1+ at both ankles.
The motor exam reveals no weakness of the muscles of the

10. lower extremities. His sensory exam is normal.
Pulmonary Exam:
His lungs are clear.
Cardiovascular Exam:
His cardiac exam demonstrates a regular rhythm, no murmur or
gallop.
Mr. Payne's abdominal exam is negative. His
straight leg raising is positive at 75 degrees on the left and
negative on the right.
His
FABER test is negative
and
sacroiliac joint is nontender.
His motor exam reveals no weakness of the muscles of the
lower extremities.
After finishing your exam together, you and Dr. Lee excuse
yourselves from the exam room for a moment.
Dr. Lee reminds you that disc herniation, a condition which is
self-limited and usually resolves in two to four weeks, remains
a working diagnosis for Mr. Payne. She says, "Let's take a few
minutes, though, to discuss some conditions we still don't want
to miss."
Now that you have a diagnosis of disc herniation with
radiculopathy for Mr. Payne, let's discuss what would you like
to do for him
You and Dr. Lee now return to Mr. Payne's exam room to talk
about treatment options with him. Dr. Lee tells Mr. Payne to
avoid strenuous activities but to remain active. Dr. Lee

11. increases the dosage of naproxen to 500 mg BID to take with
food. Since his pain is intense (7/10), he is given a prescription
for acetaminophen with codeine to take at night, when his pain
is severe. Mr. Payne declines a muscle relaxant because they
usually make him drowsy. He would like to be referred to
physical therapy as it was helpful in the past.
Three weeks later, Mr. Payne returns for his follow-up
appointment and you discover the following:
Pertinent History
Mr. Payne has had little relief with the treatment prescribed. He
is frustrated that he has been in pain for more than a month. His
pain has been progressively worse. It radiates down the lateral
part of his left leg and side of his left foot. This pain is worse
than the back pain. He does not have any problems with bowel
or bladder control and there is no weakness of his leg.
Pertinent Exam Findings
Vital signs:
stable
Neurologic:
Normal gait, but moves slowly due to pain; range of motion is
full, with pain on flexion; SLR is positive at 45 degree on the
left; motor strength intact; reflexes 2+ bilaterally at the knees,
absent at the left ankle, 1+ at the right ankle.
Dr. Lee agrees with your diagnosis of radiculopathy of S1 nerve
root with progression. She orders an MRI and sets up an
appointment to see Mr. Payne after the MRI.
ne week later, Mr. Payne returns for follow-up. You review the

12. results of the MRI report.
MRI report:
Moderate-size, herniated disc at L5-S1 with associated marked
impingement on the left S1 nerve root and mild to moderate
impingement on the right S1 nerve root. There is mild central
canal stenosis.
Annular tear with a small central disc herniation at L4-5
causing mild central canal stenosis.
You review the findings with Dr. Lee. She agrees with your
diagnosis of radiculopathy of S1 nerve root due to a large
herniated disc at L5-S1.
You call Mr. Payne two weeks later to see how he is doing. He
reports that he is doing quite a bit better. He went to an
osteopathic physician who did some manual therapy and started
him on a strict walking program. He is very encouraged and
plans on losing weight through exercise and diet.
Discuss the Mr. Payne’s history that would be pertinent to his
genitourinary problem. Include chief complaint, HPI, Social,
Family and Past medical history that would be important to
know.
Describe the physical exam and diagnostic tools to be used for
Mr. Payne. Are there any additional you would have liked to be
included that were not?
Please list 3 differential diagnoses for Mr. Payne and explain

13. why you chose them. What was your final diagnosis and how
did you make the determination?
What plan of care will Mr. Payne be given at this visit, include
drug therapy and treatments; what is the patient education and
follow-up?