What are your differential diagnoses

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Reference no: EM133623664

Case 1: A 35-year-old, healthy White male is complaining of right sided, low back pain for 1 day. The pain began suddenly after lifting a box weighing 35 pounds at work. The pain radiates down the back of his leg to his right ankle. He has tried ibuprofen and ice without relief. His pain is 8 out of 10. He denies bowel or bladder disfunction, paresthesia, motor weakness, or fever. Past medical/surgical history: no major medical illnesses; no surgical history; no previous hospitalizations.

Social history: has smoked 1 pack a day of cigarettes for 15 years.

Medications: none

Allergies: no known drug allergies

Vital Signs: temperature 98.7 degrees F; pulse, 90 beats/ minute; respirations, 18 breaths/ minute; blood pressure, 126/78 mmHg; oxygen saturation, 100% on room air

Physical examination revealed a well-nourished adult male without acute distress. Significant right paraspinal tenderness at L4-L5 was present with no midline tenderness. Straight leg raise was positive at 30 degrees to the right lower extremity. Straight leg raise was negative to the left lower extremity. The remainder of musculoskeletal examination was unremarkable. Other systems examinations were unremarkable.

1. What are your differential diagnoses? What are the subjective and objective findings consistent with the various differentials of low back pain?

2. Would you consider imaging for this patient? If so, what imaging would be recommended and why?

3. What types of clinical manifestations would indicate that the low back pain is due to a more serious issue other than musculoskeletal strain?

4. What are treatment strategies for this patient?

5. What education would be provided to the patient?

6. When should you refer this patient to a specialist?

Reference no: EM133623664

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