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 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 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 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 tw…
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