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Assignment:

Analyze the possible conditions from your colleagues’ differential diagnoses.

 

Determine which of the conditions you would reject and why.

Identify the most likely condition, and justify your reasoning.

42-year-old White Male

S.

Chief Complaint: “low back pain for the past month that sometimes radiates to my left leg.”

HPI: The patient is a 42-year-old white male who is complaining of low back pain that began one month ago.  He explains that the pain will intermittently radiate to his left leg as well.  He reports that the pain is constant and is also “sharp” at times.  He describes the pain that radiates to his left leg as a “tingling” sensation and can sometimes even feel it “all the way down to his toes.”  He rates the pain at an “8” when he is standing or walking but describes that the intensity decreases to a “4” when he is sitting or lying down.  The patient complains of intermittent numbness and tingling in his left leg that seems to have gotten worse “in the past week.”  He explains that the numbness and tingling is always worse first thing in the morning.  He also describes the pain as almost “unbearable” after working a 12-hour shift and that he even has experienced a loss of appetite on those days after working long hours.  He explains that the pain does wake him up sometimes at night. The patient explains that Aleve has been his “lifesaver,” as he does not feel that he could have worked at all if it wasn’t for taking it routinely before work.  He proceeded to verbalize that the Aleve only “took the edge off,” but that he is worried about the effect it may be having on his stomach.

Current Medications:  Centrum Vitamin for Men, one PO daily; Aleve capsule, one PO every 8 hours; over-the-counter Zantac 150 mg PO, “occasionally” at bedtime for heartburn.

Allergies:  PCN- experienced hives after taking as a teenager; Denies food or environmental allergies.

PMH:  Occasional acid reflux, history of childhood asthma, hospitalized last year with pneumonia.  Reports only surgery being tonsillectomy at age 5.  Reports that he is current with immunizations and received a tetanus injection two years ago when he cut his finger at work.

FH:  Father died at age 60 with a heart attack, mother is living and has HTN.  Maternal grandparents are living with no history of heart disease or cancer.  Maternal grandmother-type 2 diabetes; Maternal grandfather- HTN, controlled with medication.  Paternal grandmother- living and in excellent health, with no history of heart disease or cancer. Paternal grandfather died at age 72 with a heart attack.  Reports that both children are in excellent health.  Denies a history of back pain or scoliosis with maternal or paternal relatives.

SH:  Works as a nurse in the ICU at a local hospital and has been married for 15 years; they have two school-aged children.  He reports that he and his family love to spend time outdoors and that they usually hike on the weekends together.  He explains that he is very active in his local church and teaches a class there on Wednesday nights.  He denies any past tobacco use, including smokeless tobacco.  He also denies any history of illicit drug use.  The patient explains that he drank beer on the weekends in college but denies alcohol use at this time.  He reports that his family lives in the country, but states that he and his wife’s family only live one hour away and are all very supportive.  The patient reports regular use of a seat belt and was reminded of the danger of texting and driving, as he admitted that this is something that he is in the habit of doing.

ROS:

  • General:  Reports 7 lb. weight loss in the past month; Denies fevers or chills.  Reports increased fatigue due to pain waking him up at night.  Reports increased anxiety that he relates to the constant pain.
  • Skin:  Negative for rash, lesions, cysts, or wounds.
  • Cardiovascular:  Negative for chest pain, tightness, or chest pressure.  Negative for palpitations.  Denies any issues with swelling in extremities.
  • Respiratory:  Negative for shortness of breath, cough, or sputum.  Denies shortness of breath even after long hikes.
  • Gastrointestinal:  Negative for abdominal pain.  Reports some nausea when back pain is intensified but denies vomiting.  Reports normal bowel movements with no issues of diarrhea, constipation, or blood in stools.  Positive for heartburn for at least the past couple of years, especially at night.  Negative for bowel incontinence.
  • Genitourinary:  Negative for burning upon urination or frequency.  Negative for urinary incontinence.
  • Neurological:  Negative for headaches, dizziness, or fainting.  Denies head trauma. Positive for intermittent numbness and tingling in left leg, foot, and toes.  Denies numbness or tingling in any other extremities.  Denies any problems with balance or coordination.
  • Musculoskeletal:  Denies muscle weakness. Positive for constant low back pain. Positive for back and left leg stiffness upon getting up in the mornings.  Denies any other joint pain or issues.
  • Hematologic:  Negative for a history of bleeding problems.  Denies any back trauma, wounds, or lesions.  Denies any unusual bruising.
  • Lymphatics:  Negative for any swollen lymph nodes.
  • Psychiatric:  Reports no history of depression or mental disorders.  Admits to current anxiety that he relates to constant back pain.