Running head: A CASE NARRATIVE OF LOW BACK PAIN

A Case Narrative of Low Back Pain

Salena Barnes
Georgia College and State University

A CASE NARRATIVE OF LOW BACK PAIN

A Case Narrative of Low Back Pain

Patient Name: A.H.
Address: 123 ABC Street Eatonton, Ga 31024
Date of Service: 10/11/14
Referral Source: Walk-In
Data Source: Patient
Last visit: 12/12/2008 Dr. Patho for sore throat.
Chief Complaint: A.H. is a 26 y/o Caucasian male presenting with complaints of lower back
pain for about a week.
History of Present Illness
The patient is a 26 y/o Caucasian male with no significant medical history other than
seasonal allergies. The low back pain began approximately 1 week ago after assisting his brother
with stacking several hay bales. He denies any other injuries, or trauma and never played contact
sports. However, patient reported working on the farm is physically demanding. The onset of the
symptoms was sudden (Rated 8/10). The localized lumbosacral pain is described as an
intermittent aching pain with occasional muscle spasms. Exacerbated by any lifting, twisting and
bending motion (Rated a 6/10). Alleviated by sitting, resting, and lying down (Rated a 4/10).
Currently applying Icy Hot medicated patch to his lower back which minimally aides in relieving
the pain (Rated a 4/10). The pain interferes with the patients activities of daily living by limiting
his physical activities, and interferes with his relationships.

Current Medications
1. Icy Hot Medicated Patch OTC every 8 hours.

A CASE NARRATIVE OF LOW BACK PAIN

Allergies
1. Penicillin.
2. Anaphylactic reaction.
Past Medical History
1.
2.
3.
4.

Seasonal allergies.
Usual childhood illnesses.
No history of rheumatic fever or prior fractures.
Denies having transfusions.

Past Surgical History

1.
2.
3.
4.
5.

Myringotomy and Tympanostomy Tubes in 1990.

Tonsillectomy and Adenoidectomy in 2000.
Denies complications with anesthesia.
No family history of adverse reaction to anesthesia.
Will accept blood transfusions if needed.

Hospitalizations
1. Myringotomy and Tympanostomy Tubes in 1990 (Outpatient).
2. Tonsillectomy and Adenoidectomy in 2000.
Vaccinations
1. The patient has received all his childhood vaccinations.
2. Received series of Hepatitis B vaccines in 2004.
3. Tetanus toxoid booster vaccination received in 2013.
4. Denies recent flu/pneumonia vaccination.
Reproductive History

Heterosexual and has one partner.

Sexually active with wife who currently uses oral contraceptives.
Denies use of prophylactics and STD.

Social History
Patient lives in Eatonton and runs a dairy farm with family. Currently, resides in a three
bedroom home with his wife and 3 y/o son. The family is supportive of the patient and everyone
gets along well. He attends a Methodist church frequently. The patient denies tobacco, alcohol

A CASE NARRATIVE OF LOW BACK PAIN

and illicit drug use. No recent travel or sick contacts. His financial situation is stable and he has
medical insurance. The patient deals with stress by playing golf, hunting, bike riding, and
fishing.
Family History
Brother: 25 y/o, alive and well
Mother: 46 y/o, alive and well
Father: 47 y/o, alive (History of HTN)
Paternal Grandmother: Deceased at 93 y/o MI
Paternal Grandfather: Deceased at 80 y/o MI, HTN
Maternal Grandmother: Deceased at 79 y/o Breast Cancer
Maternal Grandfather: Deceased at 75 y/o MI, HTN, DM
24 Hour Diet Recall
Breakfast-Pancakes and Sausage with Orange Juice
Lunch-Garden Salad with Chicken and Apple Juice
Snack-Protein Bar and Snickers Candy Bar
Dinner-Lasagna with Garlic Bread and Sweet Tea
Review of Symptoms
General: Denies fever, chills, malaise, weight gain/loss, and night sweats.
Skin: Denies rash, itching, ecchymosis and open wounds.
Eyes: Denies blurred vision, diplopia, photophobia, discharge, visual changes and pain.
ENT: Denies hearing loss, vertigo, rhinorrhea, nasal obstruction or discharge, sore throat,
epistaxis, neck stiffness or tenderness, hoarseness, and dysphagia.
Respiratory: Denies coughing, SOB, wheezing, hemoptysis, asthma, TB.

A CASE NARRATIVE OF LOW BACK PAIN

Cardiac: Denies chest pain/pressure, palpitations, orthopnea, syncope, edema, dyspnea on

exertion.
G.I.: Denies pain, nausea, emesis, constipation, incontinence, diarrhea, heartburn,
hematochezia, and melena. Denies any changes in stool pattern, consistency or color.
G.U.: Denies dysuria, nocturia, incontinence, discharge, hematuria, urinary frequency, retention
and urgency.
MSK: +lower back pain. +Muscle spasms. Denies radiation of lumbosacral pain. Denies pain
with coughing and straining. Denies paresthesia, weakness, tingling, numbness in all extremities.
Denies saddle anesthesia.
Neuro: Denies headaches, dizziness, confusion, difficulty with speech, tremors, seizures, head
injury, LOC, syncope, incoordination.
Psych: Denies history of depression, anxiety, hallucinations, delusions, insomnia, suicidal
ideations, and suicide attempts.
Endo: Denies heat/cold sensitivity, polydipsia, and polyphagia.
Heme: Denies bruising, bleeding. No known blood or clotting disorder.
Physical Examination
Vital signs: Temp. 98.4 F, B/P 128/65, HR 62, RR 18, O2 Sat 99% (180 lbs., 72.5 inches).
General: Patient is a well-dressed and groomed male sitting upright on the exam table. No acute
distress noted.
Head: Normocephalic, no masses/lesions, cicatrices. Held erect and midline. Facial features
symmetrical, temporal artery pulsations visible bilaterally, soft and nontender to palpation, no
bruits.

A CASE NARRATIVE OF LOW BACK PAIN

Eyes: PERRLA, conjunctiva clear, sclera white, no ptosis, red reflex present bilaterally, vessels
present w/o crossing defects, no retinal hemorrhages, and visual fields intact. Vision 20/20
Ears: Tympanic membrane landmarks well visualized bilaterally. No protrusion or retractions;
Weber midline. Negative Weber and Rinne test, Whisper test 3:3.
Nose: Nares patent, no deformity, septal deviation or perforation.
Throat: Palate rises symmetrically, gag reflex present, no nodules, or masses.
Mouth: Buccal mucosa moist, pink, intact; tonsils present, dentition intact, filings noted in
lower molars; tongue midline w/o fasciculation. Pharynx not injected no exudates. Uvula moves
up midline.
Neck: No JVD. No thyroid nodules, masses, tenderness or enlargement. No masses. Full ROM.
Trachea midline.
Nodes: No adenopathy.
Chest: Symmetric, no retraction, lesions, masses or tenderness. No dullness to percussion.
Diaphragm moves with respiration. Diaphragmatic excursion 4 cm.
Respiratory: Respirations even, and unlabored. Clear to auscultation bilaterally, normal tactile
fremitus, no egophony. Symmetric chest rise and expansion without use of accessory muscles.
No adventitious sounds noted.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2. No murmur, rubs, gallops. PMI
5th mid-clavicular ICS. No heaves, bruits or thrills. Bilateral carotid, brachial, radial, femoral,
dorsalis pedis and post tibial pulse 2+. No edema noted in bilateral upper/lower extremities
Negative Homans sign.
Spine: + Paraspinal muscle tenderness and spasm, mobile, nontender, no costovertebral
tenderness, no abnormal spinal curvature noted.

A CASE NARRATIVE OF LOW BACK PAIN

Abdomen: Flat, soft non-tender w/o masses, tympany to percussion in all four quadrants, bowel
sounds present, no bruits, no hepatosplenomegaly.
Musculoskeletal: Ambulates with a steady gait. Able to tandem walk. Negative Rombergs sign.
Full ROM in all joints/extremities 5/5 (complete ROM against gravity with full resistance. No
muscle atrophy and masses noted. No joint enlargement or tenderness. No edema noted in
extremities. Positive paraspinal muscle spasm and tenderness upon palpation. Straight leg raise
causes back but not leg pain.
Skin: Pink undertone, good turgor w/o atrophy, warm to touch, no redness or cyanosis.
Generalized macules (freckles) noted. No scars noted.
Genitalia/rectum: No discharge from urinary meatus. No external lesions. Penile shaft smooth.
Testes descended bilaterally; smooth and without nodularity, induration or masses. No hernia. No
tenderness along the course of the spermatic cords and no inguinal lymphadenopathy.
Neurological: Awake, alert and oriented to person, place, time, and events. CN I-XII grossly
intact. Pinprick, light touch, proprioception and vibration intact. No atrophy, tremors or clonus.
RAM (rapid, alt. movement) finger to nose intact. No drift in extremities x four. Heel to shin
intact. All deep tendon reflexes 2+ bilaterally. Naming and repetition intact; Memory 3:3.
Negative Babinski sign.
Mental Status: Intact memory for recent and remote event, no depression, anxiety or agitation
noted.
Culture barriers/influence
None that would interfere with medical treatment per patient.

A CASE NARRATIVE OF LOW BACK PAIN

Problem List
Lower back pain
Low back pain is a common problem that most people have experienced in their lifetime.
Approximately two-thirds of the population have a reoccurrence of back pain and one-third
experience periods of disability (Haldeman et al., 2012). Lower back pain is one of the leading
reasons why people go to see their doctors and is a forerunner of job related disability(Vassilaki
& Hurwitz, 2014). The pain is often acute with symptoms lasting less than six weeks which
generally resolve in 90% of patients (Davies, 2008). Backaches have their flare ups and can
linger for a few weeks. Moreover, most people will recover and go back to their daily activities
until the flare up occurs again. If the lower back pain lasts more than three months, it becomes
chronic. However, if the pain continues for twelve months or longer, the prognosis worsens
significantly. Only a small percentage of patients require surgery (Davies, 2008; Vassilaki &
Hurwitz, 2014).
The spinal column provides support for the body and protects the spinal cord. The spinal
column is comprised of anywhere from twenty-three to twenty-five vertebrae, as well as
intervertebral disc which act as shock absorbers as the body is in motion. Besides the vertebral
column itself pain could arise from the ligaments, tendons, and muscle fascia, which also provide
added support to the spine. Therefore, low back pain can be triggered by a number of cases and
can be costly seeking the cause as well at treatment of the pain (Haldeman et al., 2012). Below is
a table of common causes of back pain.
Sources of Low Back Pain
Musculoskeletal low back or leg pain
Lumbar sprain or strain
Degenerative disk disease
Herniated disk

Prevalence
97%
70%
10%
4%

A CASE NARRATIVE OF LOW BACK PAIN

3%
Spinal stenosis
1%
Trauma
<1%
Congenital disease
Referred or visceral
2%
Nonmechanical low back pain
1%
(Data from Deyo RA. Low back pain. New England Journal of Medicine. 2001; 334:
363-370.)
Lower back pain is treated with nonsteroidal anti-inflammatory drugs or narcotics,
antidepressants, muscle relaxants, spinal manipulation, physical modalities, as well as
maintaining some degree of physical activity (Haldeman et al., 2012). However, the use of
narcotics is controversial due to potential addition, abuse, questionable effectiveness, and a high
association with mental illness co-morbidity with chronic lower back pain. Patients should be
educated on strategies to prevent lower back pain and injury which are the following: mechanical
back supports, back flexion, back extension, back mechanics and ergonomic techniques, general
fitness exercises and modifiable risk factors. The patient may choose to utilize other methods
such as acupuncture, biofeedback, traction, electrical nerve stimulation, interventional therapy,
and ultrasound therapy if conservative treatment was not helpful (Vassilaki & Hurwitz, 2014).
Obtaining a thorough history and physical on all individuals that present with lower back pain is
vital. While evaluating individuals with low back pain its of absolute importance to exclude
potentially serious conditions such as infection, spinal cord compression or cauda equine
syndrome, malignancies, and infection. Furthermore, sudden onset of severe middle or low pain
unrelieved by rest, possibly accompanied by pallor, diaphoresis and confusion in individuals
typically older that thirty could be signs of aortic aneurysm. Imaging studies should be done with
red flag signs and symptoms which are the following: new onset on pain in a patient older than
50 years older or younger than 20 years old, history of cancer, immunosuppression, unintentional
weight loss, fever, bowel or bladder incontinence, saddle anesthesia, fever, major motor

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10

weakness and severe nighttime pain or pain that is worse in the supine position (Rapid
differential diagnosis, 2002). Moreover, if the individual experiences persistent pain and
neurologic symptoms following conservative treatment after four to six weeks radiographic
imaging will be warranted and possible surgery for individuals with herniated disks, malignancy,
as well as with an infectious process. There for these individuals will need a referral to a
neurosurgeon (Yilmaz & Dedeli, 2012) . The cause of lower back pain can have a seemingly
mysterious cause, be debilitating at times, and restructure an individual life. As healthcare
providers it is essential that we identify potentially serious conditions through a thorough history
and physical examination, as well as, assess psychological and the economic situation of the
individual. In essence, healthcare providers need to take a holistic approach to grasp the extent of
the affect of lower back pain on the individual.
Diagnosis with differential
Acute Lumbosacral Strain
More common in adults age twenty to fifty years old and with individuals that engage in
strenuous work. Also, noted in children that experience a trauma or sports injury. The nature of
the symptoms are sudden and the pain is usually located in the lumbosacral region. Pain is
generally precipitated by physical activity such as lifting, and twisting. However, rest and
remaining motionless ease the pain. The individual may experience temporary muscle weakness,
paraspinal muscle spasm, and pain. Neurologic finding should be negative and some individuals
may experience limitation of motion in lumbosacral region anteriorly and posteriorly. Unless
there is a change in signs and symptoms, no diagnostic studies are necessary (Radebold, A., &
Young, C., 2012).

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11

Sciatica or Lumbosacral Radiculopathy (Herniated Lumbar Disc)

The most common cause of sciatica is a herniated disc. Herniation of the disc occurs
when the inner gelatinous inner disc material leaks out causing irritation or pinching of a
corresponding nerve root. This incidence generally occurs in adults between the age of twenty
and fifty years of age. The individuals history may include repetitive strain, lifting or trauma.
The condition is commonly occurs at the L4, L5 and S1 nerve roots. Physical findings will
include paravertebral tenderness, spasms, positive straight leg raise and sitting knee extension
produces radicular pain below the knee at less than 60 degrees. The pain generally follows the
distribution of the lumbar or sacral nerve roots and may or may not involve motor or sensory
deficits (Sciatica, 2013; Seidel, 2011).
Spondylolisthesis
Generally a common cause of back pain in growing individuals, gymnasts, and football
linemen. Pain is the result of anterior displacement of and upper vertebral body on the lower
body. This usually occurs between L5 and S1. Forward flexion may be limited and a palpable,
prominent spinous process will be palpable on examination. Surgical intervention is utilized in
high grade slips to decompress any neural segments and restore spinal alignment (Spine
Conditions, 2014; Seidel, 2011).
Ankylosing Spondylitis
This systemic inflammatory condition predominantly develops in men between twenty
and forty years old. Arises insidiously with low back pain, also involves hips and shoulders. The
intervertebral discs become inflamed and ligaments ossify. This eventually progresses to fusion,
and severe deformity of the vertebral column. The individual may present with excessive
thoracic kyphosis, rounding of the posterior thoracic spine with forward flexion. The erythrocyte

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12

sedimentation rate is elevated in these individuals and radiographic images may reveal vertebral
fusion (Spine Conditions, 2014; Seidel, 2011).
Spondylolysis
A defect in the pars interarticularis, which can be either congenital, or secondary due to a
stress fracture. Thus leading to lower back pain, muscle spasms or no symptoms. However,
symptoms are usually reported between the ages of twenty to fifty, and is an aging phenomenon
(Spine Conditions, 2014; Seidel, 2011).
Lumbar Stenosis
Hypertrophy of the ligamentum flavum, as well as the facet joints that lead to narrowing
of the spinal canal, cause entrapment of the spinal cord. This disease is more prevalent in older
men and neurologic examination is frequently normal in the early stages. Overtime, the physical
exam may show focal weakness and sensory loss. The individual generally experiences pain in
the buttocks with radiculopathy down the lower extremities while walking, standing, bending,
which is exacerbated by prolonged time frames. Some individuals experience relief with sitting
or rest and often associated with pseudoclaudication (Spine Conditions, 2014; Seidel, 2011).
Cauda Equina Syndrome
This condition is associated with lower back pain, saddle anesthesia, and bowel or
bladder dysfunction. The individual may exhibit lower extremity weakness, abnormal deep
tendon reflexes, and a positive straight leg raise. Cauda equina syndrome is a surgical
emergency.
Planned Interventions
Pharmacological Plan

May continue use of Icy Hot medicated patch as needed

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13

Prescribe Ibuprofen 800 mg PO every 8 hours

Baclofen 5 mg PO PRN TID

Labs

CBC, Renal, Magnesium, Lipid Panel, ESR, UA

Radiology

Radiographic imaging will be ordered if pain persists greater than six weeks or worsens

Non-Pharmacologic Intervention

Physical Therapy evaluation (with modalities)

Education
Patient received educational pamphlets and instructions on the strategies to prevent lower
back pain and injury, which covered the following: mechanical back supports, back flexion,
back extension, back mechanics and ergonomic techniques, general fitness exercises and
modifiable risk factors. Patient also instructed on the importance of receiving annual physicals.
Patient demonstrated proper lifting techniques and verbalized understanding.
Conclusion
The diagnosis of acute lumbosacral strain is determined due to strenuous work activity, as
well as presentation of the signs and symptoms. Will follow-up in one week unless indicated
sooner by lab work. However, if signs or symptoms persist of worsen patient is to contact office
immediately. Patient instructed to use appropriate techniques to lift heavy objects to reduce the
risk for injury to the lower back. Rather than bend over to pick up a heavy object, keep the back
straight and flex the knees to get closer to the object. Keep the object close to the body and lift
with the knees. Avoid twisting the back during the lift (Seidel, 2011).

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14

References
Davies, R. (2008). Low back pain. InnovAiT, 1(6), 440.
Haldeman, S., Kopansky-Giles, D., Hurwitz, E. L., Hoy, D., Mark Erwin, W., Dagenais, S.,
Walsh, N. (2012). Advancements in the management of spine disorders. Bailliere's Best
Practice & Research in Clinical Rheumatology, 26(2), 263-280. doi:
10.1016/j.berh.2012.03.006
Ma, Benjamin. (2013). Sciatica. National Institutes of Health. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/000686.htm
Rapid differential diagnosis. (2002). Philadelphia : Lippincott Williams & Wilkins, c2002.
Seidel, Henry. Mosby's guide to physical examination, (7th ed.). Mosby, 2011. VitalBook file
Vassilaki, M., & Hurwitz, E. L. (2014). Insights in public health: perspectives on pain in the low
back and neck: global burden, epidemiology, and management. Hawai'i Journal of
Medicine & Public Health: A Journal of Asia Pacific Medicine & Public Health, 73(4),
122-126.
Yilmaz, E., & Dedeli, O. (2012). Effect of physical and psychosocial factors on occupational low
back pain. Health Science Journal, 6(4), 598-609.
Spine Conditions Treated at Emory. (2014). In Emory Healthcare. Retrieved from
www.emoryhealthcare.org/spine/medical-conditions
Radebold, A., & Young, C. (2012). Lumbosacral Spine Sprain/Strain Injuries Treatment &
Management Medscape. Retrieved from http://emedicine.medscape.com/article/95444treatment