Pertinent Physical Exam Findings
Aged 28-year-old, Ms. Jones is an African American female who claims to experience back pain, which has been going on for three days. She claims that it happened after she ‘tweaked’ her back while helping a friend who was moving. Ms. Jone’s job description is that of a supervisor whose job includes having to stand or sit over an extended period. Other than on the day she helped her friend move by lifting a few boxes, not to be three days before the examination, she did not indulge in lifting as part of her job. Rating her pain as a 5/10, she claims that usually, it is a 7/10 while sited and a 3-4/10 while standing. To manage the pain, Ms. Jones states that she has been using two tablets of Ibuprofen she purchased over the counter over periods of 5-6 hours. Further, Ms. Jones denies any bladder or bowel incontinence, muscle weakness, tingling, and numbness. Upon further inquiry, she denies any use of illicit drugs, alcohol, and tobacco, as well as changes in her weight.
Pertinent Physical Exam Findings
Ms. Jones is a pleasant and obese 28-year-old woman of African American descent, is not in acute distress, and is alert as well as oriented. Throughout being examined, she maintains eye contact. Upon examination, her bilateral upper extremities have no muscle atrophy or joint deformity. The full range of motion of her shoulders, elbows, and wrists is noted in her bilateral upper extremities. There is no evidence of swollen joints or signs of infection that Ms. Jones shows. Additionally, Ms. Jones’ bilateral lower extremities have no muscle atrophy or joint deformity, and she has a full range of motion of her bilateral hips, knees, and ankles. Her body shows no evidence of swollen joints or signs of infection. Ms. Jones’ spine indicates flexion, extension, lateral bending, and rotation with reduced ROM – pain and difficulty. Her bilateral upper extremity strength is equal and 5/5 in neck, shoulders, elbows, wrists, hands. Finally, she has equal bilateral lower extremity strength and 5/5 in hip flexors, knees, and ankles.
Differential Diagnosis
From the observations and assessment made on Ms. Jones, there are three possible differential diagnoses. The first one is strain of her muscle – fascia and tendon of the lower back – caused by the effect of lifting the box. This is usually as a result of exerting too much pressure on the fascia as well as the tendon of the lower back (De Blaiser, De Ridder, Willems, Danneels, Vanden Bossche, & Roosen, 2017). Additionally, it is relieved by resting, which is evident in Ms. Jones’ assessment. The second differential diagnosis, in this case, is low back pain; lumbago which is characterized by soreness from spasms, and also affects on the posture and tingling in the lower back (Baker, 2017). It is also referred to as acute back pain, which is limited to four weeks and does not usually have an underlying reason for its occurrence (Knight, Deyo, Staiger, & Wipf, 2013). The final possible diagnosis is M54.9 Dorsalgia, unspecified, which is closely related to muscle strain and tear (Cordova, Azizi, & Rand, 2017).
Diagnostics
No diagnostics are needed at this particular time in Ms. Jones’ case as the assessment is pretty much conclusive.
Final Diagnosis
The final diagnosis is strain of her muscles (the fascia and tendon of the lower back) as a result of lifting the box. The strain of muscles is primarily indicated by pain in the muscles, which is usually relieved by resting, as evident in Ms. Jones’ case of sleeping as a way of reducing her pain (De Blaiser, De Ridder, Willems, Danneels, Vanden Bossche, & Roosen, 2017).
Pathophysiology of Diagnosis
Lifting the box that Ms. Jones did with no prior straining activities informs the diagnosis since exerting the back can cause muscle strain (De Blaiser, De Ridder, Willems, Danneels, Vanden Bossche, & Roosen, 2017). With the absence of other symptoms such as weight loss, fever, bladder problems, among others, Ms. Jones’ case rules out other medical issues narrowing down onto muscle strain (De Blaiser, De Ridder, Willems, Danneels, Vanden Bossche, & Roosen, 2017).
Treatment Plan
Ms. Jones’ treatment plan includes administration of Ibuprofen 600 mg by mouth every 6-8 hours as needed due to pain, and it is to be taken with food. The Ibuprofen is to last for two weeks from the day of administration commence. Additionally, Tylenol 500-1000 mg may be used for every 8 hours is to be taken for intense pain. In addition to medication, the condition needs education, and she is to be given materials that detail how she is going to practice stretching techniques for her lower back. These techniques are to help manage her muscles recovery and healing since the strain is not extreme but mild (De Blaiser, De Ridder, Willems, Danneels, Vanden Bossche, & Roosen, 2017). Adjunct therapy involving the use of topical ice or heat for comfort and as pain dictates will be also be advised. Additionally, to prevent any further strain, Ms. Jones is to be educated on proper lifting techniques that do not strain her lower back as she is still limited to lifting 10 pounds (Will, Bury, & Miller, 2018).