Looking for feedback on this case. Questions will be provided at end of blog post below case.
Script: Lumbar Disc Herniation.
Medical History: (I am listing the “Yes” remarks from intake form):
-Positive for arthritis
-Positive for sleeping difficulties
– She smokes 1/2 pack a day and 4 packs a week
– She doesn’t work out but does enjoy walking sometimes
Subjective History: 32 yo female presents with main complaint of back pain and BIL LE. It all started with Bil LE pain but she has had a history of low back pain which was just uncomfortable, but now it is unbearable. This arose during the month of August following a surgical procedure following a miscarriage (patient was unsure of procedure but I am assuming D&C). She consulted with her surgeon but he is unsure why she is having symptoms following this procedure. She was then referred to a spine surgeon who referred to PT for 4 visits until he can order an MRI.
Prior history: She has had one other miscarriage in the past. She says she is not sure why she miscarriaged then and even now. Her MD doesn’t know either. She is not sure if her mother had miscarriages either. She has one son who is 6 years old.
Date of Onset: Mid-August 2014 (4 months ago). Onset Due To: Arose after D&C.
Recent symptom trend: Since August, the pain has spread from the thighs to the low back. Pain is mostly in the thighs, but will work to the calves at times, but cannot provide any further information of why.
Verbal Pain Rating at Present: 8 /10
Verbal Pain Rating at Best: 6/10 (Over the past week)
Verbal Pain Rating at Worst: 10 /10 (Over the past week)
Quality of symptoms: She describes the back pain as unbearable at times. But for the most part, everything is just “sore”. She has trouble moving around. She feels like everything needs to pop. Her symptoms are mostly in the thighs, equally bilaterally, and circumferentially. She says this is numbness/tingling and burning. She also describes muscle spasms in the same location that is painful.
Provokes symptoms: Any movements could do it, but also she can have muscle spasms that arise just sitting. She denies any postures, movements or positions that make symptoms better or worse. Relieves symptoms: Lying down with heating pad (legs elevated). Medication as prescribed.
Medication: Prescribed muscle relaxer (Skelaxin) that she takes 1-2x/day as needed. Was prescribed a 10 day prednisone series
Sleep: She only gets half the amount of sleep than she did prior to procedure. She says she wakes up several times a night and it can keep her awake for several hours at at time. She just lies there and watches TV.
Further questioning: PT in italics, patient in normal font.
Are you having any changes in your bowel or bladder? No.
Are you having any painful urination or bowel movements? No.
Are you having any pain with intercourse? No.
Any discoloration in your urine or bowels? No.
Are you having any abdominal pain? Yes but only came on after taking Diclofenac as prescribed by MD. However, I am not taking this medication anymore due to the effects.
Where was it hurting in your abdomen? Generally in lower abdomen pointing diffusely in this region.
Do you notice the lower limb symptoms at different times of the day? Yes, it gets worse as day progresses but blames it on just being active to do daily tasks.
What are your top 3 diagnoses so far?
What other questions would you ask prior to proceeding to objective exam?