Outpatient Case Presentation

Outpatient Case Presentation:John 55 yr. M

By: Gabriella Garcia, MS409/05/2024

CC: Back Pain

History of Present Illness

John is a 55-year-old male who presents to the clinic today due to 1-week history of low back pain

CC: Back Pain

History of Present Illness

55-year-old male with a PMH of hypertension and hyperlipidemia who presents to the clinic complaining of low back pain that began one week ago. Patient reports he was helping his daughter move into her college dorm last week. He describes the pain as a constant, dull, aching pain in a belt-like distribution along his lower back that is a 6-7/10 at its worst. He reports taking over the counter ibuprofen on occassion which provides some pain relief.

Histories

PMH:

• Hypertension, hyperlipidemia

Surgeries:

• Cholecystectomy (45) - no reported complications

Medications:

• Losartan 50 mg PO qd, Atorvastatin 20 mg PO qd

Allergies:

• NKDA

FH:

• Father: HTN, DM, MI in 50s
• Mother: DM, Osteoporosis
• Uncle: Died age 53 from MI
• Brother: HTN

Histories Cont.

Social Hx:

• Lives at home with wife, son (12), and 1 cat (Morgana)
• Feels safe at home
• Currently works from home in finance
• Eats a balanced diet, primarily homecooked
• Goes for 30-minute walks with his wife in the evening

• Former smoker, 30 pack-years, quit age 50 yrs
• EtOH few times/year - 2-3 beers in one sitting
• Remote marijuana use in his 20s
• Due for annual physical

Sexual Hx:

• Sexually active with 1 female partner (wife)
• No history of STDs, not interested in screening
• No barrier protection - wife underwent BTL after last child

Review of Systems

General: Denies fever, chills, weight loss, fatigue HEENT: Denies headache, vision changes, vertigo, rhinorrhea, sore throat Pulmonary: Denies cough, hemoptysis, shortness of breath Cardiovascular: Denies diaphoresis, palpitations, angina, claudication Gastrointestinal: Denies changes in appetite, nausea, vomiting, fecal incontinence, constipation Genitourinary: Denies urinary incontinence, urinary retention, flank pain, dysuria MSK: Denies trauma, joint pain/swelling Neuro: Denies numbness, tingling, weakness, difficulty walking, headache

What other questions do you have?

Physical Exam

What would you like to examine?

P H Y S I C A L E X A M

III.

IV.

I.

II.

Vitals:BP 127/84 mmHg HR 70 bpm T 98.1°F RR 16 SpO2 98% BMI: 27 General: Alert, well-nourished male, sitting in slight discomfort Skin: Intact, warm, dry

HEENT: PERRLA, EOMI, MMM Neck: Supple, no LAD CV: RRR, S1 & S2, no edema Pulm: CTAB, no W/R/R Psych: Good judgment/insight

GI/GU: Soft, NTND, NBS No abdominal bruit No CVA tenderness Neuro: CN II-XII grossly intact, Patellar, Achilles reflexes 2+ bilaterally Normal strength, tone, sensation in lower extremities bilaterally Normal gait

MSK:No spinal misalisngment/ asymmetry No midline TTP/ step-offs TTP lumbar paraspinal muscles bilaterally Full ROM Negative SLRT

Differential diagnosis?

Work Up

Labs, imaging, other tests?

Lipids:

• Total Cholesterol: 215 mg/dL
• LDL Cholesterol: 100 mg/dL
• HDL Cholesterol: 40 mg/dL
• Triglycerides: 165 mg/dL

HbA1c:

• 5.3%

Thyroid Panel:

• TSH: 1.2 mIU/L
• Free T4: 0.9 ng/dL
• Free T3: 2.0 pg/mL

Lipase

• 50 IU/L

Amylase

• 40 IU/L

ESR

• 5 mm/hr

CRP

• <1 mg/dL

Results

CBC:

• Hgb: 15.2 g/dL
• Hct: 45.5%
• MCV: 85 fL
• MCH: 28 pg
• RDW: 12%
• Platelets: 260,000 cells/dL
• WBC: 5,600 cells/mcL
• Differetial:
• Neutrophils: 60%
• Lymphocytes: 35%
• Monocytes: 4%
• Eosinophils: 2%
• Basophils: 1%

CMP:

• Calcium: 9.3 mg/dL
• Total Protein: 7.0 g/dL
• Albumin: 4.0 g/dL
• AST: 18 units/L
• ALT: 20 units/L
• ALP: 50 units/L
• Bilirubin: 0.4 mg/dL

UA:

• Unremarkable

137

100

11

87

23

0.9

Final Diagnosis?

Diagnosis/Outcome:Lumbar Muscle Strain

• Avoid bed rest
• Physical activity as tolerated
• Naproxen 250 mg BID for pain
• 4 week follow up if pain fails to improve

Does he need an x-ray?

The ACR Appropriteness Criteria

Evidence-based guidelines to assist physicians in making the most appropriate decision regarding imaging and treatment for a specific clinical condition

Indications for Radiograph in Acute Low Back Pain

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References

• Hsu, Philip S., Carmel Armon, and Kerry Levin. "Acute lumbosacral radiculopathy: Pathophysiology, clinical features, and diagnosis."
• Knight, C. L., Deyo, R. A., Staiger, T. O., & Wipf, J. E. (2013). Treatment of acute low back pain. Uptodate.com. (Accessed on September 2, 2024.)

• Levin, K., Aminoff, M. J., Atlas, S. J., & Wilterdink, J. L. (2019). Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis. Retrieved April, 28, 2021.
• “Low Back Pain.” ACR Appropriateness Criteria, 2021, acsearch.acr.org/docs/69483/narrative/.
• Yu, H. M., & Hoffe, S. E. (2018). Epidemiology, clinical presentation, and diagnosis of bone metastasis in adults.
• Peel, T. (2021). Vertebral osteomyelitis and discitis in adults. UpToDate, Waltham, MA.(Accessed March 7, 2022.)
• Rosen, Harold N., and David Richard Walega. "Osteoporotic thoracolumbar vertebral compression fractures: Clinical manifestations and treatment."
• Wheeler, S. G., Wipf, J. E., Staiger, T. O., Deyo, R. A., & Jarvik, J. G. (2016). Evaluation of low back pain in adults. UpTo Date.