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1. RUNNING HEAD: COMMON COMPLAINTS IN PRIMARY CARE: BACK PAIN
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Common Complaints in Primary Care: Back Pain
Concordia University Mequon
Advanced Primary Care Nursing One
February, 11, 2013
Group Members:
Sarah Holtegaard, Michael Thorn

2. RUNNING HEAD: COMMON COMPLAINTS IN PRIMARY CARE: BACK PAIN 2
Jessica Frye, Laurie Hensel,
Lisa O’Brien, Dezari Dykstra

3. RUNNING HEAD: COMMON COMPLAINTS IN PRIMARY CARE: BACK PAIN 3
Differentials Pyelonephritis Lumbar Strain Herniated Disk Vertebral
Compression FX
Sciatica Abdominal
Aortic
Aneurysm
Definition Renal
inflammation,
infection,
typically
caused by
Escherichia
coli and
occurring most
frequently in
females age
18-49. Women
are more
susceptible due
to a short
urethra.
(Epocrates,
2013).
A kidney
infection can
originate from
many causes.
An obstruction
in the urinary
tract (kidney
stone,
structural
anomaly,
pregnancy,
Occurs when the
muscle fibers
are abnormally
stretched or torn
in lumbosacral
region.
Generally, found
in patients 20-50
years old that
have strenuous
occupations.
Muscles and
ligaments in the
lower back hold
bones of our
spinal column
together. If you
stretch these
muscles too far
it can cause
tears in the
tissue. The spine
becomes less
stable because
the muscles are
weakened,
causing low
back pain. The
majority of
Disc anomalies
occur secondary
to injury or
degeneration of
the annulus
fibrosus (strong
outer layer of the
disc). When a
disc herniates,
the nucleus
pulposus (jelly-
like material that
acts as a cushion
for the disc)
pushes through a
tear in the
annulus fibrosus,
resulting in
compression of a
unilateral nerve
root (Dunphy
et.al., 2011).
Radiculopathy
(pain
experienced in
the buttock, leg,
or foot) results
from nerve root
impingement
A vetebral
fracture that
collapses a
spinal vertebra
as a result of the
compression of
bone, leading to
collapse of the
vertebrae
Sciatica is a
pain, either sharp
or burning, that
is usually
associated with
numbness that
radiates down
the leg. This
subsequently,
results in pain
that can be
debilitating and
completing
ADL’s and
exercising. The
lumbrosacral
nerve root or
plexus are
inflamed and
cause this
radiating pain in
the lower back
and down the
leg.
“Abdominal
Aortic
Aneurysm is a
permanent
pathologic
dilation of the
aorta with a
diameter >1.5
times the
expected PA
diameter of that
segment, given
the patient’s
gender and body
size. This is
approx. 3cm in
most
individuals.”

4. RUNNING HEAD: COMMON COMPLAINTS IN PRIMARY CARE: BACK PAIN 4
prostatitis), or
vesicoureteral
reflux (failure
of the valve
that prevents
backflow of
urine)
(USDHHS,
2012.)
patients with
low back pain
have
lumbosacral
strain
(Lemonick,
2009, p. 6)
and/or
inflammation
that has
progressed
enough to cause
neurologic
symptoms in the
areas that are
supplied by the
affected nerve
roots (Malanga,
2012).
Subjective Questions
When did the pain start? Where is the pain located? What were you doing before the pain started? How often does it occur? Can you
rate your pain (Faces scale 1-10)? What makes it better/worse? Pain worse when standing or walking? Is the pain relieved when you
are lying down? Do you have difficulty with pain when bending or twisting? What do you use or take to help control the pain? Does
that help alleviate the pain? Have you had any recent falls, traumatic events, or motor vehicle accidents? History of (list of our
differential diagnosis) Do you have pain in the anterior abdomen? When was your last bowel movement? Any weight loss, fatigue
noted? Can you describe the pain? Pain dull or sharp? Radiating to belly? Taking long term Glucocorticoids? History of Cancer?
Describe the effect of back pain on daily activities. What limits your back motion? Post menopausal? What is your occupation?
Subjective findings
characteristic of
diagnosis
1) Typically
unilateral (can
involve both
kidneys).
2) fever, chills
3)
nausea/vomitin
g
4) back, flank,
or groin pain
5) frequent,
(1) Usually
sudden onset (2)
occurs after
turning, lifting,
twisting, or
physical activity
(3) localized
pain center to
lumbosacral
region, that
radiates to
Unilateral
radiculopathy
accompanied by
low back pain.
Preexisting
lower back pain
disappears at the
onset of the leg
pain. Difficulty
with walking,
standing,
1. Pain relieved
by lying down 2.
Sitting and
movement often
make it worse 3.
Pain in trunk not
in lower
extremities 4.
Can be gradual
onset or sudden
pain
1. Onset of
symptoms is
usually gradual
2. Pain typically
will be on one
side or the other
of the spinal
column. 3.
Patients will
typically take
Tylenol,
Abdominal, back
or groin pain.
Dizziness
(related to
hypotension)
Nausea and
Vomiting
Diaphoresis
Rapid heart rate.

5. RUNNING HEAD: COMMON COMPLAINTS IN PRIMARY CARE: BACK PAIN 5
urgent, painful
urination
6) hematuria,
pyuria
(USDHHS,
2012).
buttock and legs
(4) described as
dull, stiff and
persistent (5)
Pain is
aggravated by
moving bending,
or stretching. (6)
improved when
lying prone and
moton-less
coughing, and
sneezing. Pain
radiates from the
buttock to the
posterior or
posterolateral leg
to the ankle or
foot. Lying on
side in fetal
position or
supine with
pillows under
knees; are the
only positions of
comfort.
ibuprofen, or
other analgesics
for pain relief.
Hot and cold
packs are used
and position
changing will be
reported to help
alleviate the
pain. 4. Falls,
accidents, or an
incidence of
traumatic
mechanical
injury and cause
this pain to
gradually start.
5. Some patients
will have some
neurological
effects of nerve
pain and
numbness on the
affected side. 6.
Occupations that
set people up
with the risk of
back pain due to
non-ergonomical
situation can
cause sciatica
pain. 7. The
lower back pain

6. RUNNING HEAD: COMMON COMPLAINTS IN PRIMARY CARE: BACK PAIN 6
can cause some
patients to hold
their bowels
causing the risk
of impaction and
constipation.
Objective focused
physical exam
1) Respiratory
2) Cardiac
3) Back (CVA
tenderness)
4) Abdomen
(to r/o other
causes of n/v)
5) GU (if
pelvic or
vaginal
symptoms are
described)
5) V/S (fever)
(Kimball,
2005).
(1) Vital signs,
Height, Weight
(2) Cardiac (3)
Respiratory (4)
Musculoskeletal
:
examine/palpate
spine; ROM –
anteriorly,
posteriorly, and
laterally; gait;
sensation; leg
extension/hyper
extension; leg
raising; knee
compression;
pelvic pressure;
strength;
reflexes; pelvic
tilt (5)
Integumentary:
bruising, open
sores, trauma (6)
Neurological (7)
GI (8) GU-
Check
temperature,
pulse, blood
pressure, and
respirations.
Observe the
general
appearance; note
discomfort and
grimacing on
movement
and/or
examination.
Note evidence of
trauma with
bruises, cuts, and
fractures. Palpate
spine and
paravertebral
structures,
noting
tenderness and
muscle spasm.
Palpate for
generalized
Height loss,
Kyphosis, pain
on palpation of
spine,bending,
lifting, reaching,
Cardio/resp
exam Vitals,
Back
examination,
Straight leg
raises test ,
Assess sensation
in LE & pulses,
Deep tendon
reflexes -
Neurologic
exam. Motor
strength
1. Examining the
flexion and
extension of the
spine by having
the patient do
ROM exercises.
2. Having the
patient bend
forward, with
hands reaching
for the toes,
palpate the
spinous
processes and
assess the
contour of the
spinal column.
3. Have the
patient walk a
straight line to
assess gait.
Active and
passive ROM
exercises with
patient lying on
-Blood pressure
readings on all
four extremities
-Cardiovascular
Exam
-Neuro exam
-GI exam to
include listening
for bruits

7. RUNNING HEAD: COMMON COMPLAINTS IN PRIMARY CARE: BACK PAIN 7
rectal, prostate
and pelvic (9)
lymph nodes
(Seller &
Symons, 2012,
p. 39)
(Lemonick,
2009, p. 8-9)
tenderness over
lower back to
upper buttocks.
Examine/palpate
abdomen for
masses. Palpate
peripheral
pulses. Perform
neurologic
exam:Assess
sensation, pain
distribution, and
motor strength
(bilaterally). Test
deep tendon
reflexes and
dorsiflexion of
big toe. Note
gait and posture.
Perform
tractions tests:
straight leg
raises
(comparing
involved and
uninvolved
limb), crossed
leg raise,
Yeoman Guying,
Patrick’s test.
back. 4. Perform
the straight leg-
raising test. 5.
Assess sensation
in lower
extremities as
well as muscle
strength and
deep tendon
reflexes.
Objective findings
characteristic of
1) Fever
2) CVA
Limited ROM to
lower back
Reproduced
back pain with
Pain noted at the
level of the
The most
presenting
-Palpable
pulsatile

8. RUNNING HEAD: COMMON COMPLAINTS IN PRIMARY CARE: BACK PAIN 8
diagnosis tenderness
(typically
unilateral)
3) Hematuria
and/or pyuria
on UA
(Epocrates,
2013).
anteriorly and
posteriorly.
Local swelling
and tenderness
to lumbar area.
Neurological
assessment
usually normal.
Pain tenderness
to BLE with
sensation and
motor
examination
intact.
Paraspinal
muscle spasm
and pain.
Increased
lumbar lordosis.
Leg raising may
cause back pain,
not leg pain.
(Seller &
Symons, 2012,
p. 39)
(Lemonick,
2009, p. 8-9)
supine straight-
leg raise limited
to less than 45
degrees of leg
elevation. A
positive crossed
straight-leg
raising test; pain
in involved leg
that occurs when
lifting
uninvolved leg.
Trunk tilting
away from
affected side
while standing.
While sitting:
pain and spinal
extension
(leaning back)
when the leg is
raised is
observed.
L3-4: Weakness
in the anterior
tibialis,
numbness in the
shin, thigh pain,
and an
asymmetric knee
reflex.
L4-5: Weakness
in the great toe
fracture (focal
tenderness),
Local pain
radiating across
the back and
around the trunk,
Pain in middle or
lower levels of
dorsal spine.
Palpable
swelling at site
of vertebral
fracture
clinical sign in
the diagnosis of
sciatica is a
positive leg-
raising test.
“Ipsilateral leg
and lower back
pain between 10-
60 degree in
raising of the leg
can signify
sciatica.”
Unsteady gait,
with the patient
alleviating pain
on the affected
side by putting
more weight on
the unaffected
side.
abdominal mass.
(only found in
thin people if
AAA is very
large.)
- Decrease or
difference in
femoral pulses
-Hypotension
-Bruit over
abdomen
-SBP difference
of greater than
10mmhg
between two
arms
-Diaphoresis
-Tachycardia
-Loss of
Conciousness

9. RUNNING HEAD: COMMON COMPLAINTS IN PRIMARY CARE: BACK PAIN 9
extension,
numbness top of
the foot and first
web space, and
posterolateral
thigh and calf
pain.
L5-S1:
Weakness in the
great toe flexor
as well as
gastrocsoleus
with inability to
sustain tiptoe
walking,
numbness in the
lateral foot,
posterior calf
pain and ache,
and an
asymmetric
ankle reflex.
Diagnostics/ Labs 1) UA (WBC >
10, RBC > 5).
2) gram stain
(gram- rods,
less frequently
gram +)
3)UA culture
(bacteria >
100,000)
4) CBC
Not indicated,
recommendation
is against
routine
imaging;(Lemon
ick, 2009). As
erythrocyte
sedimentation
rate and alkaline
phosphatase
X- ray and MRI
of spine
X-rays of
dorsolumbar
spine AP and
lateral, DXA
bone density,
Diagnostic
testing can’t
show an
indicative sign of
sciatica but it
can illustrate
other issues that
are causing the
sciatica. A CT
scan or MRI can
-Radiography
- U/S of
abdomen
-CT scan if
needed
-Angiogram if
needed
-Cardiac
enzymes, EKG
etc to r/o MI

10. RUNNING HEAD: COMMON COMPLAINTS IN PRIMARY CARE: BACK PAIN 10
(leukocytosis)
5) ERS
(elevated)
6) C-reactive
protein
(elevated)
7) ultrasound,
MRI, voiding
cystourethrogr
am (if no
response to
treatment or
for recurrent
infections)
8) digital rectal
exam for men
to determine
obstruction due
to prostatitis
(Epocrates,
2013).
findings will be
normal.
Imaging studies
(Xray/MRI/CT)
for low back
pain are only to
be done after 7
weeks of
treatment unless
evidence of
motor, sensory,
trauma or
infection exists.
In the case of
lumbar strain
those s/s should
not occur (Seller
& Symons,
2012, p. 43).
show infection,
fracture, or
cauda equina
that is inflaming
the nerve and
causing lower
back pain.
vsruptured AAA
List of other
differentials for
back pain
PyelonephritisLumbar strainHerniated disk
Vertebral compression FXAbdominal Aortic aneurysm Myopathy
Degenerative Lumbosacral arthritis Spinal stenosisTumor or infection
ProstatitisIrritable bowelNeoplasm/Cancer
Herpes ZosterPostural backachePelvic: tumors, abscesses, PID
Potential
complications of
back pain
Increased risk of falls,neurological deficits including numbness and tingling.
persistent painful instability or deformity, further slipping of a herniated disc, paraplegia, decreased productivity at
work, sleeps problems depression, narcotic abuse, mortality, social isolation,
irritability, unable to perform daily activities

11. RUNNING HEAD: COMMON COMPLAINTS IN PRIMARY CARE: BACK PAIN 11
Plan/ Patient
Teaching
Primary
options:
1) Cefixime
400mg PO QD
x 2 weeks
2) Ciproflacin
500mg PO
BID x 1-2
weeks
3) Ofloxacin
200-300mg PO
BID x 1-2
weeks
*If severe
symptoms are
accompanied
by complicated
disease or
pregnancy-
hospital
admission with
IV antibiotics
Teaching:
1) increase
water intake
2) respond to
urge to void
3) Females:
void after
intercourse
(Epocrates,
Ice lower back
to reduce pain
and swelling-
20-30 minutes q
3-4 hours for 2-
3 days or after
physical
activity. Apply
heat only after
2-3 days of
icing- after
initial swelling
has decreased.
Soak in hot bath.
Take anti-
inflammatory
drugs (NSAIDS)
such as Advil,
Aleve or Motrin.
Lumbar support
like belt or
girdle when
lifting heavy
objects. Physical
therapy to
strength lumbar
area and
maintain muscle
tone in core
(abdomen and
back). Proper
Ergonomics.
Keep moving;
NSAIDS,
Watch for
signs of GI
bleed (blood
in stool, ab
pain, coffee
ground
emesis), take
with food to
avoid
stomach
erosion.
Bedrest (1-3
days)
Severe acute
pain: muscle
relaxants and
narcotics
(for 7 to 10
days)
Oral steroids
(5 days)
Epidural
injection,
Limit: sitting,
walking or
prolonged
standing,
Chiropractor
and/or
physical
therapy.
Surgical
Provide relief
from pain, oral
analgesics,
therapeutic
massage,
exercise program
when pain is
diminished, RTC
if pain gets
severe,
numbness or
weakness in
legs/feet, Cannot
control bladder
or bowels. DXA
scan results
show
osteoporosis
treat
appropriately.
1. Ergonomical
positioning in
occupation and
at home
2. Integrative
medicine
modalities:
acupuncture,
acupressure,
yoga exercises,
and chiropractor
services
3. Oral
Analgesics:
Tylenol,
NSAIDS, and
Tramadol
4. Muscle
Relaxants:
Diazepam or
Flexeril
5. Topical
Analgesics:
Salonpas or
Lidoderm
patches
Because a
ruptured AAA is
an emergent
situation and
emergent
surgery is
needed; if patient
survives surgery
teaching can be
done post op.
Teaching should
be done
regarding
bedrest
restrictions, heart
healthy diet,
blood pressure
control, activity
restrictions,
smoking
cessation, and
lowering
cholesterol.
If the aneurism
has not ruptured
and it is not large
enough to
warrant surgery
these same
teachings can be
done to prevent
the AAA from
getting larger

12. RUNNING HEAD: COMMON COMPLAINTS IN PRIMARY CARE: BACK PAIN 12
2013). note that bedrest
does NOT help.
Opioids or
muscle relaxants
may be
indicated.
intervention
if pain
persists
longer than 3
months.
Patient
Education:
Most
herniated
discs resolve
within 3 to 6
weeks;
without
residual
problems.
Follow-up in
10 days for
reevaluation.
Progressive
walking
program
Avoid lifting
heavy objects
and long
car rides.
Smoking
cessation,
weight
reduction,
good posture,
and body
mechanics
and
and additionaly
teaching should
be done to watch
for signs of a
ruptured AAA.

13. RUNNING HEAD: COMMON COMPLAINTS IN PRIMARY CARE: BACK PAIN 13
adherence to
exercise
regimen to
prevent
reoccurrence.
Guidelines
Resource Link
Epocrates
Online
https://online.e
pocrates.com/n
oFrame/showP
age.do?method
=diseases&Mo
nographId=551
&ActiveSectio
nId=21
Mayo Clinic
http://www.ma
yoclinic.com/h
ealth/kidney-
infection/DS00
593/DSECTIO
N=treatments-
and-drugs
US
Department of
Health and
Human
Services
http://kidney.ni
ddk.nih.gov/ku
National
Institute of
Arthritis and
musculoskeletal
and skin
diseases
http://www.nia
ms.nih.gov/healt
h_info/Back_Pai
n/default.asp
American
Academy of
Family
Physicians
http://www.aafp.
org/afp/1999/11
15/p2299.html
Cleveland
Clinic: Center
for Continuing
Education
http://www.clev
elandclinicmede
d.com/medicalp
ubs/diseasemana
Healthfinder.gov
http://healthfinde
r.gov/HealthTopi
cs/Category/ever
yday-healthy-
living/safety/pre
vent-back-pain
American
Academy of
Family
Physicians
http://www.aanp
.org/practice/clin
ical-
resources/clinica
l-resources-n-o
Compression FX
of the back
http://www.nlm.
nih.gov/medline
plus/ency/article/
000443.htm
Uptodate:
http://www.upto
date.com/content
s/clinical-
manifestations-
and-treatment-
of-osteoporotic-
thoracolumbar-
vertebral-
compression-
fractures
Mayo Clinic
http://www.may
oclinic.com/healt
h/sciatica/DS005
16
Medline Plus
http://www.nlm.
nih.gov/medline
plus/ency/article/
000686.htm
Uptodate
http://www.upto
date.com/content
s/low-back-pain-
in-adults-
beyond-the-
basics?source=se
arch_result&sear
ch=Sciatica&sel
ectedTitle=1%7
E3
Pub Med Health
http://www.ncbi.
nlm.nih.gov/pub
medhealth/PMH
0001215/
Uptodate:
http://www.upto
date.com/content
s/abdominal-
aortic-aneurysm-
beyond-the-
basics
Mayo Clinic
http://www.may
oclinic.com/healt
h/abdominal-
aortic-
aneurysm/DS011
94/METHOD=p
rint

14. RUNNING HEAD: COMMON COMPLAINTS IN PRIMARY CARE: BACK PAIN 14
diseases/pubs/
pyelonephritis/
OBGYN
Knowledge
Bank
http://www.nut
halapaty.net/kb
/creog_display.
asp?y=all&q=2
-3-J-2
gement/neurolog
y/low-back-
pain/
References
Abdominal Aortic Aneurism. (2010). Abdominal Aortic Aneurism.Retrieved February 12, 2013 from
http://www.mayoclinic.com/health/abdominal-aortic-aneurysm/DS01194/METHOD=print.
Abdominal Aortic Aneurism. (2012). Epocrates Online. Retrieved February 12, 2013 from Epocrates android application.
Bhimji, S. ( 2012.) Abdominal Aortic Aneurism. Retrieved Feb 19, 2013 from
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001215/.
Cash, J.C. & Glass, C.A. (2011).Family Practice Guidelines.2nd ed. pp.98-100. New York: Springer
Chou, R. (2012). Patient information: Low back pain in adults (Beyond the Basics). Retrieved February 14, 2013, from
http://www.uptodate.com/contents/low-back-pain-in-adults-beyond-the-basics?source=search_result
Dunphy, L.M., Winland-Brown, J.E., Porter, B.O. & Thomas, D.J. (2011). Primary care: The art and science of advanced practice
nursing.

15. RUNNING HEAD: COMMON COMPLAINTS IN PRIMARY CARE: BACK PAIN 15
3rd ed. pp. 303-309. Philadelphia: F.A. Davis.
Epocrates. (2013). Acute pyelonephritis. Retrieved from
https://online.epocrates.com/noFrame/showPage.do?method=diseases&MonographId=551&ActiveSectionId=21
Kimball, K. (2005). Diagnosis of acute pyelonephritis. Retrieved from
http://www.nuthalapaty.net/kb/creog_display.asp?y=all&q=2-3-J-2
Lemonick, D. M. (2009, Fall). “Oh, My Aching Back!” An evidence-based review of one of mankind’s oldest afflictions.American
Journal of Clinical Medicine,
6(4), 5-13. Retrieved from http://www.aapsus.org/articles/32.pdf
Low Back Pain Fact Sheet. (2012). National Institute of Neurological Disorders and Stroke (NINDS). Retrieved February 14, 2013,
from
http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm
Malanga, G.A., Buttaci, C.J. &Rubbani, M.(2012). Lumbosacral Radiculopathy. Retrieved from
http://emedicine.medscape.com/article/95025-overview
Mohler, E. (2012.) Patient information abdominal aortic anuerism (beyond the basics). Retrieved February 24, 2013, from
http://www.uptodate.com/contents/abdominal-aortic-aneurysm-beyond-the-basics
Sarwark, J.F, (2011). Essentials of musculoskeletal care, 4th ed. pp. 937-939. Rosemont, IL: American Academy of Orthopaedic
Surgeons.
Sciatica. (2012). Epocrates Online. Retrieved February 14, 2013, from
https://online.epocrates.com/noFrame/showPage.do?method=diseases
Seller, R.H., Symons, A.B., (2012), Differential diagnosis of common complaints. 6th ed., pp. 33-49, Philadelphia, PA: Elsevier
Saunders.
United States Department of Health and Human Services [USDHHS]. (2012). Pyelonephritis: Kidney infection. Retrieved
from

16. RUNNING HEAD: COMMON COMPLAINTS IN PRIMARY CARE: BACK PAIN 16
http://kidney.niddk.nih.gov/kudiseases/pubs/pyelonephritis/
Wheeler, A. (2013, January 8). Low Back Pain and Sciatica. Low Back Pain and Sciatica. Retrieved February 14, 2013, from
http://emedicine.medscape.com/article/1144130-overview
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17. RUNNING HEAD: COMMON COMPLAINTS IN PRIMARY CARE: BACK PAIN 17
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