Lower Back Pain Paper
Episodic/Focused SOAP Note
Patient Information: H.E, 42-year-old American male
CC: Lower back pain
HPI: The patient, a 42-year-old male, presents with a chief complaint of lower back pain for the past month. The pain occasionally radiates to his left leg. He denies any recent trauma or heavy lifting. The pain is described as aching and constant, worsened by prolonged sitting or standing and relived by taking analgesics such as Tylenol. There are no associated numbness or weakness. The patient denies any bowel or bladder dysfunction. He puts the severity at 8/10.
Location: Lower back
Onset: One month ago
Character: Aching and constant
Associated signs and symptoms: Radiation to the left leg and no associated numbness or weakness
Timing: After prolonged sitting and standing
Exacerbating/ relieving factors: Worsened by prolonged sitting or standing and relived by taking analgesics such as Tylenol. Lower Back Pain Paper
Severity: 8/10 pain scale
- Tylenol (acetaminophen) 500 mg, 2 tablets every 6 hours as needed for pain
- Amlodipine 5 mg, once daily for hypertension
Allergies: No known allergies.
PMHx: No significant past medical history reported. The patient is hypertensive and takes amlodipine for blood pressure control.
Soc Hx: The patient is employed as an office manager. He is married with two children. He denies tobacco or alcohol use. The patient reports using proper ergonomics while working at the office.
Fam Hx: No significant family history reported.
General: No weight loss, fever, chills, weakness, or fatigue.
Musculoskeletal: Reports dull pain in the lower back and occasional radiation to the left leg. No history of trauma.
Neurological: No numbness or weakness in the lower extremities.
Gastrointestinal: No bowel or bladder dysfunction.
Cardiovascular: no edema, no chest pains, no cough, no palpitations
Other systems are reviewed and are within normal limits.
General Examination: The patient is alert and oriented to place, person, time and situation, appropriate judgement, well-nourished American, dressed appropriate to the weather, no distress noted, mild discomfort due to pain in his lower back. Emotional and behavioral needs are appropriate at the present time.
Vital signs: Blood pressure: 130/80 mmHg, Heart rate: 72 beats per minute, Respiratory rate: 16 breaths per minute, Temperature: 98.6°F (oral), Oxygen saturation: 98% on room air.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Ears, nose, and throat are unremarkable.
Neck: Supple. No lymphadenopathy or thyromegaly. Full range of motion without pain.
Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops. Peripheral pulses are intact.
Respiratory: Clear breath sounds bilaterally. No respiratory distress.
Abdomen: Soft, non-tender, and non-distended. Bowel sounds present. No organomegaly or masses. Lower Back Pain Paper
- Inspection:No visible deformities, asymmetry, or skin changes in the lower back. No swelling or redness.
- Palpation:Tenderness over the lumbar paraspinal muscles and sacroiliac joints. No step-offs or bony prominences.
- Range of motion:Limited lumbar flexion and extension due to pain. Pain is reproduced with forward bending and backward extension.
- Straight leg raise test:Positive on the left side, reproducing low back and leg pain.
Neurological: Cranial nerves II-XII intact. No focal motor deficits. Sensation intact to light touch and pinprick in all dermatomes.
Skin: No rashes, lesions, or abnormalities noted.
- X-ray of the lumbar spine:Shows decreased lumbar lordosis and evidence of muscle spasms in the paraspinal muscles.
- MRI of the lumbar spine:Reveals a small central disc protrusion at the L4-L5 level causing mild compression of the L5 nerve root. Additionally, mild degenerative changes, such as disc desiccation and facet joint hypertrophy, are noted at multiple levels of the lumbar spine.
Lumbar Disc Herniation: The most likely diagnosis for this patient is Lumbar Disc Herniation. The patient’s symptoms of lower back pain radiating to the left leg, along with the MRI findings of a small central disc protrusion at the L4-L5 level causing mild compression of the L5 nerve root, are characteristic of this condition (Dydyk, 2023). The presence of decreased lumbar lordosis and muscle spasms in the paraspinal muscles could further suggest this diagnosis.
Lumbar Spinal Stenosis: This condition could also explain the patient’s symptoms and imaging findings. Lumbar spinal stenosis is a narrowing of the spinal canal in the lower back, which can put pressure on the spinal cord and the nerves that travel through the spine (AANS, 2023). The patient’s symptoms of lower back pain radiating to the leg, along with the MRI findings of facet joint hypertrophy, could suggest this diagnosis. The presence of decreased lumbar lordosis could further suggest this diagnosis (AANS, 2023).
Degenerative Disc Disease: This is a condition in which a damaged vertebral disc causes chronic pain. The patient’s symptoms of lower back pain, along with the MRI findings of disc desiccation and facet joint hypertrophy, could suggest this diagnosis (Suthar et al., 2015). The presence of a small central disc protrusion at the L4-L5 level causing mild compression of the L5 nerve root could further suggest this diagnosis.
Sciatica: This condition is characterized by pain that radiates along the path of the sciatic nerve, which branches from the lower back through the hips and buttocks and down each leg (Davis, 2022). The patient’s symptoms of lower back pain radiating to the left leg could suggest this diagnosis. The presence of a small central disc protrusion at the L4-L5 level causing mild compression of the L5 nerve root could further suggest this diagnosis.
Spondylolisthesis: This is a condition in which one of the bones in the spine slips out of place onto the bone below it. The patient’s symptoms of lower back pain, along with the MRI findings of facet joint hypertrophy, could suggest this diagnosis (Studnicka, 2022). The presence of decreased lumbar lordosis could further suggest this diagnosis. Lower Back Pain Paper
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
AANS. (2023). Lumbar Spinal Stenosis – Symptoms, Diagnosis and Treatments. American Association of Neurological Surgeons. https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Lumbar-Spinal-Stenosis
Davis, D. (2022, May 6). Sciatica. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK507908/
Dydyk, A. M. (2023, January 16). Disc Herniation. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK441822/
Studnicka, K. (2022, September 4). Lumbosacral Spondylolisthesis. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK560679/
Suthar, P. P., Patel, R., Mehta, C. H., & Patel, N. A. (2015). MRI Evaluation of Lumbar Disc Degenerative Disease. Journal of Clinical and Diagnostic Research. https://doi.org/10.7860/jcdr/2015/11927.5761. Lower Back Pain Paper