Case Study Low Back Pain

Obtain a clear chronologic narrative of problem onset, setting, manifestation, and treatment. Principal symptoms should be described. Location: Where does it hurt? Quality: What does it feel like? Quantity or severity: How bad is it? Timing (onset, duration, frequency): When does it happen? When is it worse? Setting: Where are you when it happens? Under what conditions is it worse? Factors that aggravate or relieve the pain: What makes it feel better? What makes it worse? Associated manifestations: Is there anything else you feel with it? Ask what the meaning of the symptoms is to J.C. and what impact it has on his life.

1. What are several history and assessment questions appropriate to ask J.C. in evaluating the extent of his back pain and injury?

His potbelly puts undue strain on his lower back muscles.

2. What observable characteristic does J.C. have that makes him highly susceptible to low back injury and chronic pain?

Piroxicam (Feldene), as other NSAIDs, can precipitate peptic ulceration and gastrointestinal (GI) bleeding. S/S of GI bleeding would include abdominal pain or other GI discomfort, dark stools, or bloody stools.

3. J.C. used to take piroxicam 20 mg until he developed his duodenal ulcer. What is the relationship between the two? What S/S would you expect if an ulcer developed?

Knee-to-chest: Lie on the back with knees bent at 90-degree angle and feet flat on the floor. Clasp hands behind one knee at a time and gently pull toward chest. Alternate knees. Repeat. Partial sit-ups: Lie on the back with knees flexed and feet flat on the floor, with arms extended beside knees. Inhale deeply. Tuck chin and exhale while slowly lifting shoulders from the floor. Hold position for count of five, continuing to exhale and inhale while slowly returning to resting position. Repeat. Pelvic tilt: Lie on the back with knees flexed and feet flat on the floor. Inhale deeply. Exhale slowly as you tighten buttocks and abdomen, pressing back into floor. Hold for count of five while exhaling and relax.

4. A PT teaches J.C. maintenance exercises he can do on his own to promote back health. What three common exercises would be included?

Although it is frequently used for chronic joint pain, acetaminophen is an analgesic and antipyretic but lacks antiinflammatory properties and does not stop the damage caused by chronic inflammatory processes.

5. Why would you want to use an NSAID rather than acetaminophen for pain?

J.C. is a 41-year-old man who comes to the ED (emergency department) C/O acute low back pain. He states that he did some heavy lifting yesterday, went to bed with a mild backache, and awoke this morning with terrible back pain. He admits to having had several episodes of similar back pain each year over the past 10 years. In the past the pain has been treated by diazepam, codeine, NSAIDs, and several weeks of bed rest. J.C. has a past medical history (PMH) of a peptic ulcer. He is 6 ft tall, weighs 265 pounds, and has a prominent "potbelly." The ED admitting clerk calls J.C.'s insurance company to authorize payment for treatment at your facility. J.C.'s health maintenance organization (HMO) has identified him as a consumer of "high-cost care" with poor prior outcome. The ED is authorized to perform emergency treatment only and the case manager will make a home visit within 24 hours to devise a treatment plan. The ED physician diagnoses muscular strain of the lower back and orders the following: cyclobenzaprene (Flexeril) 10 mg qid, celecoxib (Celebrex) 200 mg qd; bed rest for 2 days then gradually increase activity; ice packs to the lower back 30 minutes out of every hour. You are a case manager RN working for Grubabuck HMO and make the initial visit to J.C.'s residence. His wife lets you in and you find J.C. lying on the sofa with his knees flexed and watching videos.

J.C. is a 41-year-old man who comes to the ED (emergency department) C/O acute low back pain. He states that he did some heavy lifting yesterday, went to bed with a mild backache, and awoke this morning with terrible back pain. He admits to having had several episodes of similar back pain each year over the past 10 years. In the past the pain has been treated by diazepam, codeine, NSAIDs, and several weeks of bed rest. J.C. has a past medical history (PMH) of a peptic ulcer. He is 6 ft tall, weighs 265 pounds, and has a prominent "potbelly." The ED admitting clerk calls J.C.'s insurance company to authorize payment for treatment at your facility. J.C.'s health maintenance organization (HMO) has identified him as a consumer of "high-cost care" with poor prior outcome. The ED is authorized to perform emergency treatment only and the case manager will make a home visit within 24 hours to devise a treatment plan. The ED physician diagnoses muscular strain of the lower back and orders the following: cyclobenzaprene (Flexeril) 10 mg qid, celecoxib (Celebrex) 200 mg qd; bed rest for 2 days then gradually increase activity; ice packs to the lower back 30 minutes out of every hour. You are a case manager RN working for Grubabuck HMO and make the initial visit to J.C.'s residence. His wife lets you in and you find J.C. lying on the sofa with his knees flexed and watching videos.