Matthew Donovan, a taxi driver in his 40s presents with pain at the base of his lower spine.
Personal life:
He is married and has a son. He mentions that he sometimes has to lift heavy weights like suitcases.
Presenting complain:
Right side back pain, sharp pain in the lower back through his leg when he lifted a suitcase on Thursday.
History of presenting complain:
- Onset: started about 10 years ago
- Characteristics: continuous pain with prickling and burning sensations
- Radiation: feels pain in his buttocks, right thigh, and numbness on the little toe
- Exacerbating/Relieving factors: pain gets worse during work while lifting weights
and while sitting. he also feels intense pain while coughing or sneezing. Pain
relieves when lying on a firm surface or when standing. - Pain Severity: 7.5 on a VAS scale
- No relevant past medical or surgical history.
- No relevant drug history.
Family history:
Father experienced back pain, brothers are healthy.
Physical Examination:
- All vitals within normal limits.
- Walking test: claudication
- Posture: bent forward with a lateral right tilt.
- Spine palpation: hardness of lower back muscles.
- Reduced and painful flexion, extension and lateral flexion.
- Reduced sensation in the little toe.
- Foot movements: weak eversion, cannot walk on tiptoes.
- Lasague sign positive (40 ̊)
- Wassrmann negative, Babinsky positive.
Diagnosis:
Sciatica
Treatment and management:
- Avoid overloading back
- 2 weeks medical leave
- Physiotherapy
- NSAIDs - if the pain is unbearable and no more than 3 tabs
Visit 2:
The patient says he feels better, however, is still experiencing some pain in the lower back and right leg when sitting.
Pain Severity: 3 -3.5 on the VAS.
Physical exam:
- All vital signs within normal limits.
- Walking: Claudication
- Posture: bent forward with a lateral right tilt.
- Improved spine movement.
- Recovered right ankle reflex.
- Improved Lasague sign (80 ̊)
- Babinski and Wassermann negative.
Management:
- Continue NSAID therapy.
- Follow an exercise program.