Presenting Complaints:
(The patient, a 45-year-old male, presents with complaints of severe pain radiating from the lower back down the back of his right leg. He describes the pain as a sharp, shooting sensation that worsens with movement. The patient also reports numbness and tingling sensations in the same leg. The pain and discomfort have been present for the past six weeks, and it has significantly impacted his daily activities, including walking and sitting for prolonged periods.)
History of Presenting Complaints:
The patient’s chief complaint is the debilitating pain in his lower back and right leg. He recalls that the pain initially started after lifting a heavy object incorrectly. Since then, the symptoms have persisted and gradually worsened over time. The pain is aggravated by activities such as bending, lifting, and prolonged sitting. It is partially relieved by lying down or changing positions frequently.
Past Medical and Surgical History:
The patient has a history of occasional episodes of lower back pain in the past, but none as severe or prolonged as the current episode. He has not undergone any previous surgeries related to his back or legs. His medical history is otherwise unremarkable.
Family History:
There is no significant family history of back-related issues or neurological conditions.
Socioeconomic Status:
The patient belongs to the middle socioeconomic status, employed in a physically demanding job that involves lifting and carrying heavy objects.
Present and Pre-morbid Functional Status:
Prior to the onset of symptoms, the patient had no significant functional limitations. He was physically active and able to perform his job without difficulties. However, since the onset of sciatica symptoms, his functional status has significantly declined, and he has been unable to work or engage in regular physical activities.
General Health Status:
The patient’s overall health is good, with no other significant medical conditions.
Vitals:
- Blood pressure: 120/80 mmHg
- Heart rate: 80 bpm
- Respiratory rate: 16 breaths per minute
- Temperature: 36.8°C (oral)
Aggravating Factors:
- Bending forward or backward
- Lifting heavy objects
- Prolonged sitting or standing
- Walking or running for extended periods
Easing Factors:
- Resting in a lying down position
- Changing positions frequently
- Applying heat or cold packs to the affected area
Examination:
- Observation: No visible abnormalities or deformities
- Palpation: Tenderness and muscle spasm in the lower back and buttock region, along with the right sciatic nerve distribution
- Neurological examination: Decreased sensation and reflexes in the right leg compared to the left, positive straight leg raise test, positive crossed straight leg raise test
Sleep and 24-hour Pattern: The patient reports disrupted sleep due to pain, especially when lying on the affected side. He experiences increased discomfort during the night, which affects his ability to get a restful sleep.
Duration of Current Symptoms:
The patient has been experiencing symptoms of sciatica for the past six weeks.
Mechanism of Injury/Current Symptoms:
The symptoms initially appeared after the patient lifted a heavy object using improper lifting techniques. The subsequent strain on the lower back resulted in compression and irritation of the sciatic nerve, leading to the characteristic pain and other associated symptoms.
Progression Since the Current Episode:
The symptoms have gradually worsened since the onset. Initially, the pain was localized to the lower back and buttock region, but it has since radiated down the back of the right leg, following the path of the sciatic nerve. The intensity of the pain has increased, along with the occurrence of numbness and tingling sensations in the leg.
Significant Prior History:
The patient has occasional episodes of non-specific lower back pain in the past, but no history of prior sciatica.
Previous Treatment:
The patient has not sought any medical treatment for his current symptoms. He has attempted self-management with rest, over-the-counter pain relievers, and heat/cold therapy.
Diagnostic Test/Imaging:
No diagnostic tests or imaging studies have been performed to confirm the diagnosis. However, based on the patient’s symptoms and physical examination findings, the diagnosis of sciatica is suspected.
Differential Diagnosis:
- Lumbar disc herniation
- Lumbar spinal stenosis
- Piriformis syndrome
- Sacroiliac joint dysfunction
- Lumbar spondylolisthesis
Postural Observation:
No abnormalities are observed in the patient’s posture.
Precaution and Contraindications:
Avoid activities that exacerbate the symptoms, such as heavy lifting, prolonged sitting, and bending forward.
Functional Movement Analysis (Sign):
The patient demonstrates limited range of motion in forward flexion, extension, and rotation of the lumbar spine due to pain.
Quick Screening Tests/Clearing of Additional Joint Structures:
No significant abnormalities or joint pathologies are observed during the screening tests.
Range of Motion (ROM):
The patient exhibits limited range of motion in lumbar flexion, extension, and rotation due to pain and muscle guarding.
Special Tests:
- Straight Leg Raise Test: Positive on the right side, reproducing radiating leg pain below the knee.
- Crossed Straight Leg Raise Test: Positive on the left side, reproducing contralateral leg pain below the knee.
Assessment:
The patient presents with symptoms consistent with sciatica, likely resulting from lumbar disc herniation. However, further diagnostic imaging is required to confirm the diagnosis.
Problem List/Complaints:
- Severe lower back pain radiating down the right leg
- Numbness and tingling sensations in the right leg
- Limited range of motion and functional limitations
- Sleep disturbances due to pain
- Inability to perform work-related activities
Treatment:
- Pain management: Prescribe non-steroidal anti-inflammatory drugs (NSAIDs) to alleviate pain and reduce inflammation.
- Physical therapy: Refer the patient for physical therapy to improve range of motion, strengthen core muscles, and reduce symptoms.
- Epidural steroid injection: Consider this intervention if conservative measures fail to provide adequate relief.
- Patient education: Educate the patient about proper lifting techniques, postural adjustments, and home exercises for self-management of symptoms.
Prognosis:
The prognosis for sciatica is generally favorable with conservative treatment approaches. Most patients experience significant improvement within a few weeks to months. However, the prognosis may vary depending on the underlying cause and individual factors.
Goals:
- Reduce pain and discomfort
- Improve range of motion and functional abilities
- Enhance sleep quality
- Facilitate a safe return to work and daily activities
Interventions:
- Medication management
- Physical therapy sessions including exercises, stretching, and manual therapy techniques
- Epidural steroid injection if indicated
- Home exercise program to maintain and improve strength and flexibility
- Ergonomic modifications to work and home environments
Patient Education:
- Proper lifting techniques to prevent further injury
- Importance of maintaining good posture and body mechanics
- Benefits of regular exercise and physical activity
- Self-management strategies for pain relief, including heat/cold therapy and rest
- Signs of worsening symptoms and when to seek further medical attention
Patient/Family Education:
- Educate family members about the condition, treatment plan, and potential challenges the patient may face
- Encourage family support and involvement in the patient’s recovery process
- Provide resources for additional information and support, such as online forums or patient support groups
Discharge Plan:
The patient will be discharged with a prescription for pain medication and a referral for physical therapy. A follow-up appointment will be scheduled to assess the response to treatment and make any necessary adjustments to the management plan. The patient will be instructed to contact the healthcare provider if symptoms worsen or if any new concerns arise.