Advanced Health Assessment
Advanced Health Assessment
Advanced Health Assessment
Back pain
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
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42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
Patient Information:
R.E, 42-year-old African American male
Subjective
CC: “Lower back pain”
HPI: A 42-year-old black African American male who came to the clinic today for complaining of lower back pain which he reported started a month ago. The patient stated that the pain sometimes radiates to his left leg.
Location: Lower back
Onset: One month ago
Character: Sharp, constant, radiating to left leg
Associated signs and symptoms: None
Timing: Starts when at work
Exacerbating/ relieving factors: Any movement. Ibuprofen helps to relief the pain temporarily.
Severity: 7/10 pain scale
Medications:
Ibuprofen 200mg 3 tablets every 6 hours PRN for lower back pain.
Amlodipine 10mg daily for hypertension x1 years.
Allergies: No known drug allergy, no food allergy, no seasonal allergy and No known allergy to latex/rubber.
PMHx:
Hypertension diagnosed one year ago.
Influenza vaccine November of 2020.
Tdap vaccine 2018.
Pneumonia: Not yet had any pneumococcal vaccine.
Up to date on all childhood immunizations.
Past surgical history: None.
Social History: Mr. R.E is happily married with three children. He has a bachelor’s degree in medical laboratory and works in the hospital setting. Mr. R.E denies ever smoking, but he drinks Corona beer occasionally and during festive period with friends and family. He denies using any illicit drugs and the thought of suicidal ideation. He goes to the gym at least 1-2 times in a week and walk around his neighborhood to keep him physically active and healthy. He loves dancing as a hobby and going for vacations with his family. The patient reported that he loves to maintain his activities of daily living and dress according to weather, as for his instrumental Activities of Daily Living he said he manages his finances and financial assets by paying his bills early. Mr. R.E loves his traditional African food and occasionally eat out. The patient reported that he keeps to safety measures by putting on his seatbelt and not texting while driving, he also reported having a working smoke detector and a security camera in his house. He has a good family support system for his wife and children. He sleeps 6-8 hours per night.
Family History:
Mr. R.E mother is still alive, age 70, has hypertension and type 2 diabetes mellitus. The Father is still living; he is 72 years old who has asthma.
Maternal grandmother deceased at age 78, had a stroke, she was diabetic.
Maternal grandfather, deceased at age 80, had prostate cancer.
Paternal grandmother deceased at age 70, from chronic obstructive pulmonary disease (COPD)
Paternal grandfather age 95, still alive had asthma.
Brother age 55 has type 2 diabetes mellitus.
Son, age 20, no health issues
Daughter age 16. No health issues.
Daughter 12, no health issues.
General:
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