Lbp Case Study Essay

1. Discuss how the history conducted by the intern is used to guide subsequent patient assessment and diagnostic processes.
A patient’s medical history is a thorough evaluation of the signs and symptoms that the patient presents with. When evaluating a patient’s medical history is important to address such questions as what positions alleviate or aggravate the symptoms; how long have the symptoms persisted for; are the symptoms chronic or acute; did the patient suffer from an injury; and has the patient sought out treatment, and if so, what kind of treatment?
In my clinical observation, the patient was a 24-year-old female who presented to the clinic with complaints of pain in the lower back and more specifically in left buttocks area, dull pain in the posterior part of the thigh down to the calf and foot. The patient indicated that walking upstairs or prolonged sitting causes discomfort. The patient also mentioned that the pain began a few months ago but has progressively gotten worse, and the onset was not acute but rather a dull pain that has with
time gotten worse. The patient has not suffered from any vehicular accidents, sporting injuries, or any other known trauma that could have resulted in the presented symptoms. The patient has not sought any treatment for the current symptoms. The evaluation also reviewed the patient’s family history, more specifically for any known cases of arthritis, or any other of joint degeneration.
2. Discuss how the differential diagnosis (DDX) created by the intern is used to guide subsequent patient assessment and diagnostic processes.
Lower back pain [LBP] is abundant in the population, with LBP generally encompassing one of the subsequent conditions: entrapment of the sciatic nerve, herniation of the nucleus pulposus, trauma, muscular spasm resulting from chronic or overuse, or piriformis syndrome.
The chiropractic method of diagnosing this particular syndrome comprises a full examination and evaluation of the patient’s spine and pelvis region as well as the associated musculature. Neurological, orthopedic, and functional examinations are also carried out. Many daily activities can irritate the discomfort caused by piriformis syndrome; however, they are not specific and are not reliable for diagnostic purposes. A diagnosis of piriformis syndrome is usually deduced through a course of eliminating other probable conditions that may be resulting in signs and symptoms; conditions such as sacroiliac joint dysfunction or disc herniation of the
lumbar.
3. Discuss how the examination plan created by the intern/staff doctor and related procedures are used to refine and focus the DDX to arrive at a working diagnosis (Dx).
Based off of the patient’s medical history, signs, and symptoms the intern arrived at a working diagnosis of piriformis syndrome. The patient tested positive for a constricted piriformis muscle by experiencing discomfort when she had her foot pointing outwards versus the right foot while lying supine. Static and manual palpation of the muscle indicated a tight and inflamed muscle which was tender to the touch with pain radiating down the posterior of her left leg. Rotation of the hip, whether by external rotation (resisted) and internal rotation (passive) resulted in discomfort. Either resisted external rotation or passive internal rotation of the hip may increase the pain.
There was no need for imaging.