Musculoskeletal /  arshpreet /  21 February 2020 /  18 views

 

Background for video vignette. 

 

Diagnosis: 

Acute low back pain - Discogenic 

 

Context of assessment:   

Initial musculoskeletal assessment in outpatient setting 

 

Table 7: Background information for musculoskeletal vignette 

 

DEMOGRAPHIC INFORMATION

 

Setting 

Physiotherapy outpatient clinic 

 

Gender 

Male  

 

Patient age 

30 ‐ 40 

 

Occupation 

Floor Tiler 

 

Patient Build 

Medium 

 

Main Presentation 

Acute exacerbation of low back pain Discogenic in nature

 

CLINICAL HISTORY

 

Reason for attending physiotherapy 

An acute episode of low back pain with intermittent posterolateral thigh pain 

 

History of presenting condition 

5 days ago while laying tiles at work went to stand up after prolonged flexion and reported severe pain in the low back and buttocks bilaterally. Presented to ED and CT performed. Prescribed Mobic and Panadeine Forte for pain and referred to Physiotherapy for review. 

 

Investigations 

CT – L4‐5 broad-based disc protrusion without thecal sac compression 

 

Special Questions 

No bladder or bowel changes No saddle paraesthesia No unexplained weight loss Pain with cough or sneeze Sleep disturbed due to pain at night – difficult to get comfortable No THREADS No P+N or numbness 

 

Pain Behaviour 

Pain and stiffness worse in am Movement dependant otherwise 

 

Past Medical History 

HTN medication controlled, History depression 

 

Medications 

Coversyl HTN, Mobic and Tramal Current Pain, Panadol IM LBP, Cipramil Depression 

 

Social History 

Lives with wife and 2 children - son aged 10 and daughter aged 13 in 2‐level house with 13 internal stairs.    

 

Occupation 

Self‐employed floor tiler and is involved in mainly manual duties. 

 

Functional History 

Independent with all daily activities, active occupation but a sedentary lifestyle. Not currently involved in any regular exercise and exercise tolerance is able to walk greater than 45 minutes. 

 

Patient Goals 

Reduce pain and return to normal function Return to work

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