Patient: 46-year-old, African American male. Height 6’0′ Weight 104 kg. Divorced, 3 children. Employed full-time as a roofing contractor.
Chief Complaint: “The pain in my right leg and lower back just won’t go away.” Patient reports the pain has subsisted for the last five months.
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History: Patient drinks daily, approximately two to three drinks. Denies drug or alcohol use. Patient has a history of torn left ACL during football injury, and a hospitalized episode of pancreatitis. Flu vaccination up to date. No known allergies. No prescriptions. Patient reports taking ibuprofen 600mg as much as four times per day for pain.
Family history: Patient was adopted and so denies knowledge of familial medical history. He has heard though that both his mom and dad were very young when he had him and may have been using drugs. He believes they are still alive.
Subjective: Patient reports eight out of ten pain in his lower back and even more in his right posterior thigh. Sudden movements, sitting, coughing, and sneezing exacerbate the pain. He reports some relief with heat therapy. It has persisted daily for the last five months or so and is described as a sharp pain in the thigh and an aching/throbbing pain in the lower back. Patient denies numbness or tingling (Buttaro, Trybulski, Polgar-Bailey, Sandberg-Cook, 2017). Patient denies injury and cannot recall any remarkable preceding event.
Objective: Spinal examination reveals no obvious observable abnormalities or asymmetries. Lumbar spine range of motion is limited and accompanied by reported pain, particularly with forward flexion (Buttaro et al., 2017). Dorsal and post-tibial pulses are +2 bilaterally, extremities are warm. Straight leg test is positive for pain when right leg is flexed from hip at 45 degrees (Buttaro et al., 2017).
Assessment: MRI of spine will be ordered to rule-out herniation, stenosis, nerve compression, or fracture. Spine specialist referral. Lab studies ordered, including: CBC, BMP, ESR, CRP and ANA (Buttaro et al., 2017). There are several differential diagnoses at this time. Patient does not have pain below the knee and no measurable neurological deficits. Pain is greater in the posterior thigh than the lower back and therefore radiculopathy is suspected (Buttaro et al., 2017).
Non-pharmacological: As patient has reported difficulty sleeping and conducting his normal, daily activities, he will be referred to physical therapy. He is encouraged to engage in core-strengthening exercises. He is also encouraged to alternate ice and heat while at home to minimize pain (Buttaro et al., 2017).
Pharmacological: As patient has already been medicating with NSAIDs (and irresponsibly so), this first-line treatment will be skipped. Low dose cyclobenzaprine will be initiated for minimal toxicity risk (Arcangelo, Peterson, Wilbur & Reinhold, 2017). Close monitoring of this new medication will occur, therefore low dose initiated without refill. Follow-up appointment scheduled for three weeks. Medication education provided, including possible side-effects, proper administration, and when to contact provider.
Prescription: Cyclobenzaprine 5mg tablet by mouth three times daily. #90. Refills: zero.
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