Patient Initials: MP Subjective Data:

Discussion #1

Patient Initials: MP Subjective Data:The patient presents to the clinic with complaints of sharp, stabbing lower back pain that radiates down his left leg for the past 2 weeks. The patient states the pain initially started two weeks ago while he was lifting a box at work. For pain relief, he used an ice pack and took ibuprofen. The pain got better within the next 3 days. However, last weekend, while playing softball with his daughter, the pain came back worse than before. Patient states the pain is so bad and debilitating, that he is barely able to get out of med in the morning. The patient describes the pain as sharp and it radiates down his left leg to his ankle.

Chief Compliant: Mr. Payne states he is having “sharp and stabbing pain on the left side of his back” after he lifted a box 2 weeks ago. He states the pain got better after three days but it returned after playing softball. MP states his pain is causing him to have “trouble getting out of bed”.

History of Present Illness:MP is a 45-year-old Caucasian male who presents today in clinic complaining of lower back pain. Mr. Payne’s past medical history includes: well controlled diabetes, hypertension and hyperlipidemia both which are fairly-controlled.

Onset:2 weeks ago

Location: Lower back on the left side; radiates down left leg

Duration: Intermittent chronic back pain

Characteristics: Sharp and stabbing

Aggravating factors: Activity, lifting, sitting for a long period of time

Relieving factors: Pain is better when he lies down

Treatment: Ice, Ibuprofen, Naproxen

Severity: Patient describes severe lower back pain where he is unable to get out of bed. Patient states his pain is a 7 out of 10 on approved pain scales.

PMH/Medical/Surgical History:MP denies any surgical history or drug allergies. The patient’s medications include: Metformin 500mg 2 twice daily, Glyburide 5mg 2 twice daily, Amlodipine 2.5mg daily, Lisinopril 40mg daily, and Simvastatin 40mg daily.

Significant Family History: MP denies family history of inheritable diseases

Social History:Mr. Payne works as a truck driver and he lifts about 20 to 35 pounds about 4 hours during his work days. The patient states he is married and has 2 daughters. MP states that he quit smoking 2 years ago. He also admits to drinking 1 to 2 beers occasionally on the weekends. The patient denies IV drug use.

Review of Symptoms:

General:Denies fever, chills, weight loss, or recent trauma except for when he lifted a 10-pound box at work, unrelenting night pain.

Integumentary:Denies skin changes.

HEENT:Denies headache, vision changes, sore throat or trouble swallowing.

Cardiovascular:Denies chest pain, palpitations, edema, or shortness of breath.

Respiratory: Denies shortness of breath or cough.

Gastrointestinal:Denies nausea, vomiting, changes in bowel habits, or bowel incontinence.

Genitourinary:Denies dysuria, change in frequency, or problems with bladder control.

Musculoskeletal:Admits to low back pain which radiates down his left leg.

Neurological:Patient denies numbness or weakness in legs.

Endocrine:Denies polydipsia or polyuria.

Hematologic:Denies bruising, bleeding, or infections.

Psychologic:Denies depression, anxiety or problems with sleep.

Objective Data: Vital Signs:BP –130/82 mmHg ; P – 80 beats/min, regular ; R – 12 breaths/min; T – 98.6 Fahrenheit; Wt. – 170 pounds; BMI – 24 kg/m2 Physical Assessment:

General: Well-appearing 45-year-old male in moderate distress. A&O x 3

Integumentary: No rash, unusual bruising, or prominent lesions

HEENT: Normocephalic; PERRLA; No thyromegaly, adenopathy or masses noted. Lungs: Bilaterally clear lungs to auscultation without wheezes, rales, or rhonchi. Heart: Regular heart rate and rhythm, no murmurs, rubs, or gallops. No edema. Abdomen: Soft, non-tender, without organomegaly or masses. Normoactive bowel sounds heard in four quadrants.

Extremities/Pulses: Warm and well-perfused, no cyanosis, clubbing, or edema.

Musculoskeletal:Normal curvature of the spine; Tenderness on palpation of left lumbar paraspinous muscle with increased tone; Normal gait, but moves slowly due to pain. Full range of motion with pain on flexion.

Neurologic:Straight leg raise (SLR) test is po

:The patient presents to the clinic with complaints of sharp, stabbing lower back pain that radiates down his left leg for the past 2 weeks. The patient states the pain initially started two weeks ago while he was lifting a box at work. For pain relief, he used an ice pack and took ibuprofen. The pain got better within the next 3 days. However, last weekend, while playing softball with his daughter, the pain came back worse than before. Patient states the pain is so bad and debilitating, that he is barely able to get out of med in the morning. The patient describes the pain as sharp and it radiates down his left leg to his ankle.