A 55-year-old man presents with a history of dull low back pain that began about 10 days ago and is getting worse.

A 55-year-old man presents with a history of dull low back pain that began about 10 days ago and is getting worse. It is present all day, is accompanied by some stiffness, but it does not radiate to any other location. It seems associated with prolonged sitting and/or bending. Ibuprofen helps relieve the pain and he is most comfortable lying down. He has experienced an episode of this type of pain in the past and it resolved spontaneously. The pain was not associated with any specific precipitating event. His employer insisted that the patient be evaluated before returning to work.

CC: “I’m tired of this back pain.”

The physical exam reveals no visible abnormalities of the back, but he does have some paraspinal tenderness to palpation in the L3–L5 region. Lumbar flexion is markedly diminished because of pain, but otherwise his range of motion is almost normal.

Questions:

1. What other history in addition to a description of the pain should you obtain?

2. What are some specific exam techniques that should be used when examining this patient? What is the rationale behind some of these assessment techniques? What information is supplied? (Think anatomy and physiology.)

3. In many disorders, determining the precise location of the pain and sorting through the differential diagnosis is useful in evaluating most patients with pain. Is that true with low back pain such as this patient presents with?

4. Should you order x-ray films or other imaging exams?

5. What are the “red flags” of low back pain?

6. How would you manage the patient with low back pain? Address pharmacologic and physical measures as well as other advanced practice nursing interventions.

7. What health promotion strategies are especially important for this patient atthis point in time and WHY?

8. What complementary therapies might help this patient at this point in time and/or in the future? Support with evidence from the literature.

9. What type of follow-up should this patient have? Patient education? What specific types of exercises should be recommended?

10. When should the patient be permitted to return to work?

11. How would you bill for this visit?