Respond to post in 2 paragraphs, add additional information.
-Jack is a 36 yo Asian pacific male who comes to your clinic with a complaint of Low Back Pain (6 of 10). It began 2 days ago after he lifted a heavy box at work. He denies previous instances of low back pain. He has been unable to work due to the pain which is also disturbing his sleep. He describes the pain as sharp, especially with movement. He had been taking 800 mg of ibuprofen every 12 hours at home and reports it helps a bit with the pain. He denies any other related symptoms.
What diagnostics do you think should be done?
According to Metzger, (2016), patients presenting with concerns for pathology or fracture, such as a history of trauma, should have two-view X-ray imaging (anterior-posterior and lateral) performed immediately, with the addition of flexion/extension views for any concerns of spinal instability. If neurologic involvement or other serious underlying pathology is plausible, the study of choice is magnetic resonance imaging (MRI).
What are the main diagnosis and the differential diagnosis?
The main diagnosis is non-radicular low back pain, spinal stenosis, LBP with radiculopathy, ankylosing spondylitis.
What treatment would you order for him?
Most cases of NSLBP, and even lumbar radiculopathy, resolve after a few weeks of treatment. Pain relief and rest would be my first line of treatment to help improve strain and daily function. Common treatment options include the use of oral medications for pain such as Acetaminophen (first drug of choice) or NSAID’s. These drugs can be alternated and when alternated can help reduce the risk of GI upset and acute liver failure. Muscle relaxants such as Tizanidine or Cyclobenzaprine work well when taken together with an analgesic. Topical medications such as Lidocaine pain patches or Capsaicin also assist in muscle pain relief. Physical Therapy exercises are beneficial for muscle main as are spinal manipulation therapy, traction, transcutaneous electrical nerve stimulation (TENS), heat packs, and back supports are also very beneficial.
What is his prognosis?
Jack’s prognosis can be very positive with full restoration to the strained area if he is compliant with resting the site, taking his medications, and following his therapy. Jack can also benefit from taking a body mechanics course to help with proper lifting.