Subjective
- Patient: Lambargo, 80 years old white male;
- Chief complaint: low back pain;
History of present illness
The pain started ten days ago when he woke up. He did the hard gardening job bending over pulling weeds the day before the problem occurred, therefore, he considered that work as a reason for the back pain. It is not the first time Lambargo has low back pain, and he waited for 10 days, thinking that it would disappear. However, it remains persistent and worsens when he sits for too long or tries to stand up. The pain was rated as 7-8, described as dull, constant, sharp during rapid moves, and it radiates to the right side and all back. There were no recent injuries, traumas, and the back pain he had before had been related to overdoing some activities. The problem does affect sleeping, yet the Lambargo admits that the pain complicates getting up. He denies any incontinence or other issues related to urine, bowel, and bladder. He also denies any muscle pain, weakness in the legs, numbness, or tingling.
Past medical history
Lambargo had prostate cancer ten years ago, he has Hyperlipidemia now. He developed hypertension during the last year and got a pre-diabetes condition due to blood sugar levels. In 2010, he had a prostatectomy and had the prostate removed with radiation. Due to these surgeries, he has erectile dysfunction, and his wife is fine with it. He did not discover any other types of pain for the last three months. He had a physical 6 months ago, it showed a good health condition, and no PSA was detected as he has no prostate. He does not have any food or environmental allergies, yet he is allergic to penicillin, which causes a rash. Family illnesses: his older brother has type II diabetes and high cholesterol. His parents died of old age, and his younger sister does not have any medical problems.
Medications
He takes one pill of Lipitor 20mg and one of Lisinopril 20mg daily. Now Lambargo also takes two pills of Ibuprofen 200mg at once daily due to the low back pain. He does not use any herbs or vitamin supplements.
Review of systems
He denies weakness, fatigue, dizziness, fever, night sweat, muscle aches, and abdominal pain. His weight is stable, he does not have any palpation complications, chest pain, or irregular rhythm. Lambargo denies burning, the urgency of urine, skin rash, lesions, shortness of breath, swelling in the ankles. He has no joint swelling, hips, knees, hands, stiffness, redness, or heat, yet his range of motion in the joint is limited. He has never used a wheelchair, cane, or walker and has no fall history. Immunizations: flu shot last year, Pneumonia vaccination 2 years ago, shingles shot and tetanus were 5 years ago.
Social history
Lambargo is retired, he is a former banking financial planner. He lives with his wife, they have been married for 50 years, they have 3 children and 8 grandchildren who live nearby. He spends time with family, receives a lot of support, and feels independent while doing daily tasks. He walks the dog for 30 minutes 5 days a week as physical activity but cannot do it now due to the back pain. He drinks wine a couple of times a month, has never smoked or taken any drugs. He eats small amounts, does not follow any dietary advice, and only eats long before sleeping.
Objective
T= 98.4
HR = 74
R = 16
BP = 134 /72
Spo2 99% RA
Height = 5 feet 6 inches
Weight = 160
BMI = 25.1
General appearance
Lambargo is 80 years old white male, NAD, sits on the chair and looks alert. His s1 and s2 are normal; no murmur, heart rhythm and rate are regular, no auscultate, percuss, palpate, and aorta size is 2cm. His abdomen is a little rounded, bowel sounds x4, non-tender, no masses discovered in deep palpitation, he does not have CVA tenderness. Femoral, popliteal, posterior tibial, pedal pulses are 2+ bilaterally. Lambargo’s skin has mild Kyphosis, yet there is no deformity, ecchymosis, redness, swelling, or rash; the skin is pink, warm, dry. The back palpitation showed mild tenderness over the paravertebral muscles at L3 to L5 on the right side and no pain to the palpation of spinal prosthetics, no tenderness with percussion. He has a negative bilateral straight leg raise, muscle strength is equal. He can flex to 45 degrees and extend to 30 degrees, if leans from side to side, motion bilaterally decreased to 10 degrees from 35. Rotation to the left is 30 degrees and 10 degrees to the right due to the discomfort. Urine check for UTI: negative for blood, protein, bacteria, glucose, specific gravity equals to 1.020.
Assessment
The complaint might signal about the recurrence of cancer, and it could be bone metastasis. The problems with rotation and high BMI might be a symptom of underlying osteoarthritis. He can also have a ruptured aortic aneurysm as the pain is constant, and his age is at the risk group. Physical work he did before pain and its location can signal about the herniated disk.
Differential Diagnosis
- Bone metastasis (C79. 51);
- Underlying osteoarthritis (M19.9);
- Ruptured aortic aneurysm (I71.3);
- Herniated disk (M51.26).
Plan
- Medications: increase Ibuprofen to 400-600mg three times a day, use cold and heat packs, and lidocaine patch to ease the pain; physical therapy if the problem remains.
- Further testing: check PSA, back X-Ray, LS Spine X-Ray with 2 views, UA.
- Patient Education: prevention from lifting, pushing, pulling heavyweights, and warning about low back strain, its cautions, and consequences.
- If the pain continuously remains the same, or its rate grows to 10, reach out to the emergency for help.
- The patient’s back condition will be examined during the following up in 1-2 weeks.