Lower Back Pain Intake - Adult

Subjective:
Chief Complaint:
Spinal surgery follow-up.

History of Present Illness:
The patient is a post-operative follow-up case after spinal surgery due to a car accident. They report experiencing significant pain at the surgical site, described as raw, along with sciatic pain. The pain began approximately two days ago following a long drive of about an hour and a half, which is longer than usual for the patient. The pain is exacerbated by prolonged sitting, and the patient reports that nothing has provided relief so far. They have been taking Tylenol #3, approximately six to eight tablets daily, but have run out of the medication. The patient denies any current issues with bladder or bowel control, although they experienced such problems earlier post-surgery. Additionally, the patient mentions a history of blood in the urine for the past three months, which has not been investigated with imaging or further testing.

Past Medical History:
The patient has no history of spinal injuries or chronic back conditions.

Past Surgical History:
The patient underwent spinal surgery following a car accident. The surgery was performed to address injuries sustained during the accident. The patient reports experiencing complications post-surgery, including initial issues with bladder and bowel control, which have since resolved. There is no mention of the specific type of spinal surgery performed or the surgical team involved.

Family History:
The patient has no significant family history of musculoskeletal disorders.

Social History:
The patient is a refugee and has recently experienced changes in activity levels due to a long drive, which exacerbated their back pain.

The Review of Systems:
No loss of bladder control. No loss of bowel control. No known kidney disease.

Current Medications:
The patient is currently taking Tylenol #3, approximately six to eight tablets daily, but has run out of the medication. They are also prescribed naproxen 500 mg orally three times daily, gabapentin 300 mg orally twice daily, and pantoprazole 40 mg orally once daily.

Allergies:

• The patient has no known drug allergies.

Objective:
Vital Signs:
The patient's vital signs are not documented in the encounter.

Physical Examination:
General Appearance: Patient appears in no acute distress.
Back Examination: Inspection reveals no deformities or abnormal curvatures. Palpation notes localized paraspinal muscle tenderness without bony tenderness.
Range of Motion: Restricted lumbar flexion due to pain; extension and lateral movements are full.
Neurological Examination: Normal strength and reflexes in the lower extremities. Negative straight leg raise test.

Test Results:
Consider ordering lumbar spine X-rays if trauma history or MRI if red flags for neurological involvement are present.

Assessment:
Problem:

1. Acute lumbar pain (724.5), likely musculoskeletal in origin.

Differential Diagnosis:
- Herniated disc: No leg pain or neurological symptoms to suggest radicular involvement.
- Spinal stenosis: Absence of neurogenic claudication.
- Kidney stones or infection: No urinary symptoms or fever.

Plan:

• Prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) for analgesia, including specific medication, dosage, and duration.
• Refer for physical therapy focusing on strengthening and flexibility exercises.
• Advise on proper lifting techniques and ergonomic workplace setups.
• Educate about the importance of maintaining an active lifestyle and proper postural habits. Discuss pain management and the expected course of recovery.
• Schedule a follow-up visit in 2 weeks to assess progress. Advise patient to return sooner if symptoms worsen or new symptoms develop.