Episodic/Focused SOAP

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?

Patient Information:

Patient Initials: M.S.

Age: 42

Gender: Male

Subjective Data:

Chief Complaint: Lower back pain

History of Present Illness: A 42 years old male complaints lower back pain for 1 month. He

also reports that sometimes pain radiates to his left leg.

Location: Lower Back, Left Leg

Onset: From the past month

Character: Will enquire the character of pain but pain could be deep inside the bone or just upper

surface of the back or leg.

Associated Factors: Will inquiry after examination such as fever, chills, headaches or dizziness

Reliving Factors: Massage or spray that makes the patient feel better.

Current Medications: No current medications were reported by the patient.

Allergies: No known drug, food or environmental allergies.

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PMHx: Hypercholesterolemia

Soc Hx: He was an electrician and enjoyed outdoor activities. He denied smoking or drug abuse.

Fam Hx: Married having three children, two daughters, and one son.

ROS:

GENERAL: No complaint of fever, chills, weight loss, or fatigue. The only complaint of lower

back pain.

HEENT: No abnormalities noted, denies any other pain in the body. Due to older age, blurred

vision reported. No hearing loss.

SKIN: No rash, itching or allergy

CARDIOVASCULAR: Denies any abnormality

RESPIRATORY: Denies any respiratory complication

GASTROINTESTINAL: Denies any complication

GENITOURINARY: No complications were reported in the urinary system

NEUROLOGICAL: Do not report any history of seizure, gait disturbance, movement

impairment or mental capacity. No problems were reported with thinking patterns, coordination

or communication.

MUSCULOSKELETAL: Reported back pain which radiates sometimes to the left leg for one

month. The patient denies any redness or swelling in the joint.

HEMATOLOGIC: No bleeding or anemia

LYMPHATICS: No history of lymphatic issues

PSYCHIATRIC: Do not report any anxiety or depression

ENDOCRINOLOGIC: Do not report fever, chills, sweating or cold

ALLERGIES: No allergies were reported

Objective Data:

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Physical Exam:

VITAL SIGNS

Temperature 100.1

BP 130/80

Pulse 78

Weight 182lb Height 5’11

GENERAL: 42 years old male patient is alert, oriented, cooperative and active. He walks with

slight limp due to lower back pain. Rate the current pain at 6 out of 10.

HEENT: No facial tenderness, no exudates seen. Nasopharynx and pharynx without lesions,

erythema or exudates. Warm dry skin without any patches. No swelling noted on the neck.

CHEST/LUNGS: Lungs are clear to auscultation anteriorly and posteriorly with equal symmetry.

No wheezing, coughing or rhonchi.

CARDIOVASCULAR: Heart rate normal

Diagnostic Tests:

X-Ray Lumbar Spine: Lumbar spine X-ray is an imaging test that helps the physicians to view

the anatomy of lower back pain (Barr, Chopko & Wong, 2016)

Cervical Spine CT Scan: A cervical spine CT scan is a medical procedure that uses specialized

X-ray equipment and computer imaging to create a visual model of your cervical spine. The

cervical spine is the portion of the spine that runs through the neck (McMordie & Gillis, 2019).

Differential Diagnosis:

Herniated Lumbar Disc:

A herniated disc occurs when the gel-like center of a disc ruptures through a weak area in the

tough outer wall. A herniated disk is a condition that can occur anywhere along the spine, but

most often occurs in the lower back. It is sometimes called a bulging, protruding, or ruptured

disk. It is one of the most common causes of lower back pain, as well as leg pain or “sciatica.”

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Diagnosis usually includes CT lumbar spine, an X-ray and an MRI (Jordan, Konstantinou &

O'Dowd, 2016).

Sciatica:

Sciatica refers to pain that radiates along the path of the sciatic nerve, which branches from your

lower back through your hips and buttocks and down each leg. This nerve is the body’s longest

nerve and one of the most important ones, as it has a direct effect on the ability to control the

legs/feet (Bernstein, Malik, Carville & Ward, 2017). Diagnosis is usually done with a physical

exam that will include testing the muscle strength and reflexes to determine if the pain is a result

of doing so. Also, a CT lumbar spine, X-ray and an MRI will be done (Ramaswami, Ghogawala

& Weinstein, 2017).

Muscle Strain:

A muscle strain, or pulled muscle, occurs when the muscle is overstretched or torn. This usually

occurs as a result of fatigue, overuse, or improper use of a muscle. Strains can happen in any

muscle, but they're most common in your lower back, neck, shoulder, and hamstring (McHugh &

Tyler, 2019). A physical exam is done, and possibly an X-ray to rule out other diagnoses.

Resting, with the use of NSAIDs is the most common course of treatment.

Spinal Stenosis:

Spinal stenosis is a narrowing of the spaces within the spine, which can put pressure on the

nerves that travel through the spine. Spinal stenosis occurs most often in the lower back and the

neck. Spinal stenosis is most commonly caused by wear/tear changes in the spine related to

osteoarthritis (Lurie & Tomkins-Lane, 2016).

Ankylosing Spondylitis:

Ankylosing spondylitis is a form of arthritis that primarily affects the spine, although other joints

can become involved. It causes inflammation of the spinal joints (vertebrae) that can lead to

severe, chronic pain and discomfort. X-rays show changes in joints and bones, though the visible

signs of ankylosing spondylitis may not be evident early in the disease (Taurog, Chhabra &

Colbert, 2016).

References:

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Barr, J. D., Chopko, B. W., & Wong, W. (2016). X-Ray Guided Technique in Lumbar Spinal

Canal Stenosis: MILD. In Spinal Canal Stenosis (pp. 49-74). Springer, Cham.

Bernstein, I. A., Malik, Q., Carville, S., & Ward, S. (2017). Low back pain and sciatica: summary

of NICE guidance. Bmj, 356, i6748.

Jordan, J. L., Konstantinou, K., & O'Dowd, J. (2016). Herniated lumbar disc: injection

interventions for sciatica. BMJ clinical evidence, 2016.

Lurie, J., & Tomkins-Lane, C. (2016). Management of lumbar spinal stenosis. Bmj, 352, h6234.

McHugh, M. P., & Tyler, T. F. (2019). Muscle strain injury vs muscle damage: Two mutually

exclusive clinical entities. Translational Sports Medicine, 2(3), 102-108.

McMordie, J. H., & Gillis, C. C. (2019). Cervical Spine Fractures Overview. In StatPearls

[Internet]. StatPearls Publishing.

Ramaswami, R., Ghogawala, Z., & Weinstein, J. N. (2017). Management of sciatica. New

England Journal of Medicine, 376(12), 1175-1177.

Taurog, J. D., Chhabra, A., & Colbert, R. A. (2016). Ankylosing spondylitis and axial

spondyloarthritis. New England Journal of Medicine, 374(26), 2563-2574.

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Hi Nzekwe,

I enjoyed reading your post, it is very interesting. If the bilateral pain occurs in the man of older

age, the possible diagnosis will be osteoarthritis. In this case, the patient is an active sportsman,

you diagnosed correctly. Patellar tendinitis is an injury to the tendon connecting kneecap

(patella) to the shinbone. Patellar tendinitis, also known as jumper's knee, is most common in

athletes whose sports involve frequent jumping such as basketball and volleyball (Slotkin et al.,

2018). In this case, the patient is also a young player of basketball and due to regular jumping in

sports, he experienced bilateral knee pain. In this condition, along with pain relief medications,

physical therapy is a good approach for patients to relieve them from pain. The goal of physical

therapy is to reduce pain and inflammation and to stretch and strengthen leg and thigh muscles. A

therapy session generally includes a warm-up period, ice or massage for knee, stretching

exercises and strengthening exercises (Nuhmani & Muaidi, 2018).

References:

Slotkin, S., Thome, A., Ricketts, C., Georgiadis, A., Cruz Jr, A. I., & Seeley, M. (2018). Anterior

knee pain in children and adolescents: overview and management. The journal of knee surgery,

31(05), 392-398.

Nuhmani, S., & Muaidi, Q. I. (2018). Patellar Tendinopathy: A Review of Literature. Journal of

Clinical & Diagnostic Research, 12(5).

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Hello Njoku,

Thank you for the informative post. After reviewing the case study and differential diagnosis, it

is mainly possible that the patient is experiencing from an ankle sprain. An ankle sprain occurs

when the strong ligaments that support the ankle stretch beyond their limits and tear. Ankle

sprains are common injuries that occur among people of all ages. They range from mild to

severe, depending upon how much damage there is to the ligaments (Janssen, 2018). When an

ankle is injured with a sprain, tendon injury, or fracture, inflammation occurs. Blood vessels

become "leaky" and allow fluid to ooze into the soft tissue surrounding the joint. White blood

cells responsible for inflammation migrate to the area, and blood flow increases as well. Further

changes are swelling because of increased fluid in the tissue, Pain because the nerves are more

sensitive and Redness and warmth caused by increased blood flow to the area. The most common

medications used for ankle sprains are anti-inflammatory pain medications that both reduce pain

and help control inflammation (Vuurberg et al., 2018).

References:

Janssen, K. W. (2018). Infographic: Ankle sprain treatment and prevention timeline. Br J Sports

Med, 52(15), 953-954.

Vuurberg, G., Hoorntje, A., Wink, L. M., Van Der Doelen, B. F., Van Den Bekerom, M. P.,

Dekker, R., … & Smithuis, F. F. (2018). Diagnosis, treatment and prevention of ankle sprains:

update of an evidence-based clinical guideline. Br J Sports Med, 52(15), 956-956.

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