Name: John Doe
Chief Complaint: Chronic back pain
The patient, John Doe, presents to the clinic today with a chief complaint of chronic back pain. He reports that the pain has been bothering him for the past five years and has been gradually worsening. He rates the pain as a 7 on a scale of 1 to 10 and describes it as a dull, aching sensation in the lower back. The pain is constant, aggravated by prolonged sitting or standing, and relieved by lying down. John states that the pain interferes with his daily activities and has negatively impacted his quality of life.
Additionally, John reports occasional episodes of numbness and tingling in his right leg when the pain is more intense. He denies any recent trauma or injury to his back. He admits to trying over-the-counter pain medications, but they have not provided sufficient relief.
John has a medical history of hypertension, for which he takes medication daily. He denies any history of diabetes, heart disease, or cancer. He reports a sedentary lifestyle and does not engage in regular exercise. His family history is negative for any significant medical conditions.
On physical examination, John appears well-groomed and in no acute distress. Vital signs are within normal limits. Inspection of the back reveals no visible abnormalities or deformities. Palpation of the lumbar spine reveals tenderness over the lower lumbar region, particularly on the right side. Range of motion is limited due to pain, with forward flexion causing increased discomfort. Deep tendon reflexes are symmetric and intact. There is no evidence of muscle weakness on manual muscle testing.
Based on the patient’s history and physical examination findings, the following differential diagnoses are considered:
1. Chronic mechanical low back pain: The patient’s symptoms and physical exam findings suggest chronic mechanical low back pain, which is commonly caused by musculoskeletal issues such as muscle strains and degenerative changes in the spine.
2. Lumbar radiculopathy: The patient’s occasional episodes of numbness and tingling in the right leg suggest possible lumbar radiculopathy, which occurs when a nerve in the lower back is irritated or compressed, resulting in radiating pain and sensory disturbances.
A. Non-pharmacological interventions:
– Physical therapy: The patient will be referred to a physical therapist for evaluation and treatment. Therapeutic exercises and stretching will be prescribed to improve flexibility, strength, and posture.
– Heat and cold therapy: The patient will be instructed to use heat or cold packs at home to alleviate pain and reduce inflammation.
– Ergonomic modifications: The patient will be educated on proper body mechanics and provided with recommendations for adjusting his workstation and daily activities to minimize stress on the back.
B. Pharmacological interventions:
– Non-steroidal anti-inflammatory drugs (NSAIDs): The patient will be prescribed NSAIDs, such as ibuprofen or naproxen, to help reduce pain and inflammation. He will be advised to take them as needed and follow package instructions for dosage and duration.
– The patient will be scheduled for a follow-up visit in four weeks to assess the effectiveness of the treatment plan and make any necessary adjustments. During this visit, the patient’s adherence to the non-pharmacological interventions will be evaluated, and further recommendations or referrals may be made as needed.
In conclusion, John Doe presents with chronic back pain and occasional radicular symptoms in the right leg. The initial management plan includes non-pharmacological interventions, such as physical therapy and heat/cold therapy, as well as pharmacological interventions with NSAIDs. Follow-up will be conducted to assess the patient’s response to treatment and make appropriate modifications as necessary.