A 42-year-old male visits the clinic complaining of lower back pain

Posted: May 5th, 2020

Assessing Musculoskeletal Pain

Patient Information:

Initials – SJ Age – 42 Sex – M Race – White

Chief Complaint (CC):

Lower back pain that sometimes radiates from the left leg.

History of Present Illness (HPI):

A 42-year-old male visits the clinic complaining of lower back pain. The patient explains that the pain began one month ago. He also explains that the pain sometimes radiates from the left leg. The patient is currently taking ibuprofen 800mg OTC Q4H PRN for a week to relieve the pain, but with little progress. The pain is affecting his movement, and the severity of the pain is 7 out of 10.

Current Medications:

Ibuprofen 800mg OTC Q4H PRN for a week to relieve the pain.
Metformin 500mg daily to lower blood sugar levels.

Allergies:

Allergic to penicillin, not allergic to hay, cold or dust, and no other allergies to food, water, or drugs.

Past Medical History (PMHx):

Started experiencing lower back pain one month ago. He continues to take his medication for type 2 diabetes. Diabetes is well-controlled. All vaccines are up to date.

Social History (Soc Hx):

The patient works at a local gym and goes hiking over the holidays. The patient is divorced, but he lives with his three sons and one daughter who are 10, 13, 15, and 12 respectively. He is not sexually active since they separated from his wife. He denies alcohol consumption or drug abuse. He attends a church service on Sunday at a Catholic church.

Family History (Fam Hx):

The patient’s father died 5 years go after they both succumbed to a heart attack and hypertension. His mother died 3 years ago after suffering from a stroke. He has three sisters who are all healthy. His children are all healthy, and he has no grandchildren.

Review of Systems (ROS):

GENERAL:
No unintentional weight loss or gain for the last 12 months. He denies any fever. The patient complains of lower back pain that radiates to his left leg.

HEENT: Eyes – He denies of blurred vision or yellow sclera or sensitivity to bright light. He uses sunglasses since he is shortsighted. Ears – He denies hearing problems, pain, or discharge from his ears. Nose – He denies pain, nasal congestion, or running nose. Throat – He denies any swallowing problem or pain, no tonsil problems or

SKIN: He denies skin rashes, bruises, lesions, itchiness, or dry plaques.

CARDIOVASCULAR: The patient complains of no discomfort such as chest tightness, edema, palpitations, and angina.

RESPIRATORY: He denies breathing problems, coughing, sputum, or shortness of breath.

GASTROINTESTINAL: The patient denies loss of appetite, eating disorder, blood in the stool, or diarrhea.

GENITOURINARY: He denies any difficulty in passing urine or burning sensation.

NEUROLOGICAL: He denies headache, seizures, falls, poor bowel, or bladder control.

MUSCULOSKELETAL: The patient reports no broken bone or fracture or muscle pain. He only reports lower back pain that radiates that sometimes radiates to the left leg.

HEMATOLOGIC: The patient denies bleeding gums, anemia, or bruising.

LYMPHATICS: The patient does not complain of any tonsils or enlarged lymph nodes.

PSYCHIATRIC: The patient denies any mood changes, anxiety, depression, or suicidal thoughts. He reports that he is generally in good mental health and does not take any medication for mental health issues.

Assessment:

The patient, a 42-year-old male with a history of type 2 diabetes and lower back pain that radiates to the left leg, has been taking ibuprofen 800mg OTC Q4H PRN for a week with little progress. The pain affects his movement, and the severity of the pain is 7 out of 10. Further examination is required to determine the cause of the pain.

Plan:

Further examination is required to determine the cause of the lower back pain. A physical examination will be conducted to assess the musculoskeletal system, and the patient may need to undergo imaging tests such as an X-ray, MRI, or CT scan. The patient may also be referred to a specialist for further evaluation and management. Pain management options will be discussed with the patient, including non-pharmacological treatments such as physical therapy, exercise, and lifestyle modifications, as well as pharmacological treatments such as muscle relaxants, analgesics, or anti-inflammatory drugs. The patient will be advised to continue taking his metformin medication for type 2 diabetes as prescribed.