NUR 607 Module 7 Milestone Two Example

Milestone Two: Focused Musculoskeletal and Neurologic Assessment of Acute Low Back Pain in a 42-Year-Old Warehouse Worker

[Student Name]

Southern New Hampshire University

NUR 607: Advanced Health Assessment

Milestone Two

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone Two: Focused Musculoskeletal and Neurologic Assessment of Acute Low Back Pain in a 42-Year-Old Warehouse Worker

Acute low back pain is among the most common reasons adults see a primary care clinician, and most episodes improve within weeks regardless of treatment. A small fraction are caused by fracture, cancer, infection or nerve compression that needs urgent care. Because the usual plan for uncomplicated back pain is to avoid imaging and encourage activity, the documentation carries a special burden: it must show that the serious causes were asked about and examined for. This milestone documents a focused assessment of a worker with acute back pain. It shows how a complete red flag history, a structured neurologic examination and an honest account of the limits of each test support a conservative plan.

Subjective

Chief concern: "my back went out lifting at work."

History of present illness: Mr. G. is a 42-year-old warehouse worker who felt a sudden pull in his lower back three days ago while lifting a 20 kg box from floor level with a twist. The pain is across the low back, more on the left, and spreads into the left buttock and the back of the left thigh, stopping above the knee. He describes it as a deep ache with sharp spasms, 7 of 10 with bending and 3 of 10 lying on his side. It is worse with sitting for more than 20 minutes and better with walking slowly and with heat. He has taken ibuprofen 400 mg twice with partial relief. He has had two similar episodes in the past five years that resolved within two weeks.

Red flag review: he denies saddle-area numbness, hesitancy when starting his stream, urinary retention or incontinence and loss of bowel control. He denies leg weakness, foot drop and tripping. No fever, chills, night sweats or unexplained weight loss. No history of cancer, injection drug use, recent infection or spinal procedure. No long-term corticosteroid use and no known osteoporosis. No pain that is worse at night or unrelieved by any position. No major trauma such as a fall from height or motor vehicle crash.

Past history: hypertension on amlodipine 5 mg daily. Allergies: none. Social history: works full shifts lifting and loading; smokes half a pack a day for 20 years; drinks four to six beers on weekends. He is worried about losing pay if he misses work.

Objective

Vital signs: blood pressure 136/86 mm Hg, pulse 80, temperature 36.7 degrees Celsius, weight 94 kg.

Inspection and gait: walks slowly with a slight forward lean but without limp; able to walk on heels and on toes without difficulty. No skin lesions, bruising or abrasions over the spine. Mild loss of lumbar lordosis. No scoliosis on forward bending.

Palpation: tenderness and muscle spasm of the left lumbar paraspinal muscles from L3 to L5. No midline tenderness to palpation or percussion over the spinous processes. Sacroiliac joints nontender.

Range of motion: lumbar flexion limited to fingertips at mid-shin by pain; extension to 10 degrees with pain; lateral bending reduced on the right.

Straight leg raising: supine, raising the left leg reproduces low back pain at 70 degrees without pain below the knee; right leg to 80 degrees without pain. Crossed straight leg raising negative.

Neurologic examination by root: Strength 5 of 5 bilaterally for hip flexion (L2 and L3), knee extension (L3 and L4), ankle dorsiflexion (L4 and L5), great toe extension (L5) and ankle plantar flexion (S1). Reflexes: patellar 2+ and symmetric (L4), Achilles 2+ and symmetric (S1). Sensation to light touch and pinprick intact over the medial leg (L4), dorsum of the foot and first web space (L5) and lateral foot (S1). Perianal sensation not tested; the patient denies saddle numbness, and the examination would be performed if any bladder, bowel or saddle symptom were reported.

Interpreting the Findings

Pain radiating into the buttock and thigh is common in mechanical back pain and does not by itself mean nerve root compression. A true radicular pattern usually spreads below the knee in a dermatomal distribution, and a positive straight leg raise reproduces that leg pain, not back pain, between about 30 and 70 degrees. Mr. G.'s test reproduced back pain only, which is recorded as negative. The test's limits matter: in a systematic review of surgical series, straight leg raising had a pooled sensitivity of 0.91 but a specificity of only 0.26 for disc herniation, while the crossed test was more specific at 0.88 but much less sensitive (Deville et al., 2000). A negative straight leg raise with a normal neurologic examination therefore makes a significant herniation unlikely.

Red flags also need interpretation. One systematic review showed that most guideline red flags barely change the probability of fracture or cancer, while a few, such as a history of cancer, prolonged corticosteroid use, older age and severe trauma, change it substantially (Downie et al., 2013). Mr. G. has none of the informative ones.

Assessment

Acute nonspecific low back pain with left somatic referred pain to the buttock and thigh, without radiculopathy and without red flags for fracture, malignancy, infection or cauda equina syndrome. This fits the guideline category in which imaging and further testing are not recommended at the first visit (Chou et al., 2007). Contributing factors include heavy lifting with twisting, prior episodes and smoking. His concern about lost pay is a recognized barrier to recovery and is addressed in the plan.

Plan

No imaging. Early films or scans in uncomplicated back pain add cost and incidental findings without speeding recovery, which is why the joint guideline advises against them at the first visit (Chou et al., 2007). Treatment follows the ACP recommendation to start with nonpharmacologic therapy: superficial heat, staying as active as tolerated and avoiding bed rest. If medication is needed, an NSAID or a skeletal muscle relaxant is appropriate (Qaseem et al., 2017); he will use naproxen 500 mg with breakfast and supper, for no more than 10 days, with his blood pressure checked at follow-up since NSAIDs can raise it. A work note recommends modified duty with no lifting above 10 kg for two weeks rather than time off. He was advised to call or go to the emergency department for new numbness in the groin, trouble urinating or controlling bowels, leg weakness or foot drop, fever or pain that becomes constant and severe. Follow-up in two weeks, sooner if not improving. Smoking cessation was offered, since smoking is associated with worse back pain outcomes.

Conclusion

This write-up justifies a conservative plan by documenting what was ruled out: every red flag asked and answered, a normal neurologic examination by root and a straight leg raise interpreted with its known limits. A reader can see why imaging was not ordered and what would prompt it.

References

Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, J. T., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), 478-491. https://doi.org/10.7326/0003-4819-147-7-200710020-00006

Deville, W. L., van der Windt, D. A., Dzaferagic, A., Bezemer, P. D., & Bouter, L. M. (2000). The test of Lasegue: Systematic review of the accuracy in diagnosing herniated discs. Spine, 25(9), 1140-1147. https://doi.org/10.1097/00007632-200005010-00016

Downie, A., Williams, C. M., Henschke, N., Hancock, M. J., Ostelo, R. W., de Vet, H. C., Macaskill, P., Irwig, L., van Tulder, M. W., Koes, B. W., & Maher, C. G. (2013). Red flags to screen for malignancy and fracture in patients with low back pain: Systematic review. BMJ, 347, Article f7095. https://doi.org/10.1136/bmj.f7095

Qaseem, A., Wilt, T. J., McLean, R. M., & Forciea, M. A. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166(7), 514-530. https://doi.org/10.7326/M16-2367