Reference no: EM133955149

Questions

A 39 year-old female presents to the Primary Care clinic with chief complaint: Back Pain X 3 weeks. The patient reports she does not remember a specific episode initiating the onset. She notices the pain mainly when she is at work as a toll taker on the turnpike, where she has to stand/twist/reach for up to 10 hours. She reports the pain as "across my entire low back and right buttock, going down into the back of my right thigh." She denies numbness or tingling to back, hip or extremities. She has tried her prescription ibuprofen 800mg every 6 hours without relief (Rx was prescribed for dysmenorrhea). She states what helps the most is lying down and putting ice on her back, which leaves her with a "dull ache". Reports pain as "7" on a 10 point scale if she is moving around. Pain is at its worst later in the day after work, and states "I've never had back pain like this before!".

Past Medical Hx: Kidney stone 2 years ago treated with lithotripsy. Gravida 1 Para 0 Ab 1. Dysmenorrhea X 8 years. Anemia 8 years ago, resolved spontaneously with diet and management of dysmenorrhea. No other hospitalizations or surgeries. Immunizations are up-to-date.

Family Hx: not available Social Hx: lives with boyfriend, uses condoms for contraception. One glass of wine each day. Smokes 1/2 ppd since age 16. Medications: Ibuprofen 800mg po q 6 hrs PRN. Allergies: NKDA

ROS: mostly noncontributory; denies N/V, constipation/diarrhea, dysuria, hematuria, weakness in extremities, falls or near falls.

Physical Exam and Vital Signs: BP 142/84 mmHg P 88 bpm R 22 breaths/min T 98.40 F Ht 66 inches Wt 224 lbs BMI 36.15

General/Skin: overweight, Hispanic female, appears quite uncomfortable, unable to sit still for any length of time/repositions frequently. She is well groomed and speech appropriate. Skin is W/D, no lesions/rashes to exposed areas.

HEENT: noncontributory. Chest/Lungs: CTA bilaterally, no witness SOB. Heart: RRR, no murmur/rub/gallop. Abdomen: normal BS, nontender, no organomegaly or masses, no guarding.

Back/Spine: no external lesions or masses; tension of paraspinal muscles palpable; no excessive warmth; generally tender over low back; no tenderness specific to costovertebral angle.

Musculoskeletal/Neuro/Extremities: sensation present and normal along the L4, L5, and S1 dermatomes. Straight-leg raises result = pain in low back on right at 30 degrees, but there is no pain in the legs; pain occurs on left at 45 degrees with some pain in the posterior thigh; no shooting pain or paresthesias into calf on raising her hed during raises. Extremities= reflexes 2+ at patella bilaterally, 1+ at Achilles bilaterally, no Babinski signs present; ROM=side bending 30 degrees bilaterally, flexion 20 degrees, extension 5 degrees, rotation 10 degrees bilaterally without pain; Strength testing = 4/5 bilaterally with foot dorsiflexion and plantar flexion; Gait = antalgic and slow (obviously painful) but symmetrical and steady; able to do heel walk and toe walk; no pain in back on compression downward on top of head.

Laboratory results: urine dip negative with sp gr 1.015.

Answer the following questions based on the information provided:

1. Identify the risk factors this patient presents for Low Back Pain.

2. What are the reported subjective symptoms suggesting spine/disk etiology?

3. What physical exam findings suggest spine/disk etiology?

4. What is the most likely diagnosis and pathophysiology?

5. Differentiate this condition with Spondylolisthesis.