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Please see attachment for instructions.

Week 9 case study

CASE STUDY 1: Headaches A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occur above the eyes and spreads through the nose, cheekbones, and jaw.

The Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. (attached)

· Consider what history would be necessary to collect from the patient in the case study you were assigned.

· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

· Identify 
at least five

 possible conditions that may be considered in a differential diagnosis for the patient.

· Use APA format and validate the diagnosis with references (updated on the last 5 years)

Main diagnosis.

· Acute Sinusitis

For the differential diagnosis I want you to consider:

· Common cold

· Allergy rhinitis

· Migraine without aura

· Tensional headache.

· temporomandibular joint or jaw pain

Please see attachment for instructions.

Episodic/Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race


S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.


O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)


A

.

Differential Diagnoses (list a minimum of 5 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.


P.
  

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least five evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

© 2021 Walden University, LLC

Page 1 of 3

Please see attachment for instructions.

Assessment Tools, Diagnostics, Growth, Measurement, and Nutrition in Adults and Children

Assignment Option 1: Adult Assessment Tools or Diagnostic Tests: 3–4 pages, not including title and reference pages. Include five references of last 5 years in appropriate APA formatting.

Diagnostic test: Mammogram

Include the following:

Search the Walden Library and credible sources for resources

explaining the tool or test you selected.

Search the Walden Library and credible sources for resources

explaining the tool or test you selected.

· Introduction. Explaining the tool or test you selected.

· Include a description of how the assessment tool or diagnostic test you were assigned is used in healthcare.

· What is its purpose?

· How is it conducted?

· What information does it gather?

· Based on your research, evaluate the test or the tool’s validity and reliability,

· Explain any issues with sensitivity, reliability, and predictive values.

· conclusions

Please see attachment for instructions.

Week 4

Skin Comprehensive SOAP Note Template

Patient Initials: _______ Age: _______ Gender: _______

SUBJECTIVE DATA:

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Health Maintenance:

Immunization History:

Significant Family History:

Review of Systems:

General:

HEENT:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Neurological:

Psychiatric:

Skin/hair/nails:

OBJECTIVE DATA:

Physical Exam:

Vital signs:

General:

HEENT:

Neck:

Chest/Lungs:.

Heart/Peripheral Vascular:

Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

Diagnostic results:

ASSESSMENT:

PLAN:
This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

7

Comprehensive Soap Note

References

American Academy of Dermatology. (n.d.). Petechiae, purpura, and vasculitis.

Retrieved from file:///C:/Users/User/Downloads/Petechiae–Purpura-and-Vasculitis.pdf

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015).

Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Gupta, J., Kandhari, R., Ramesh, V., & Singh, A. (2013). Glomeruloid

hemangioma in normal individuals. Indian Journal of Dermatology, 58(2), 160.

doi:10.4103/0019-5154.108088

Kim, J., Park, H., & Ahn, S. K. (2009). Cherry Angiomas on the Scalp. Case

Reports In Dermatology, 1(1), 82-86. Retrieved from Walden Library database

Sanz, V., Martorell, A., Alegria-Landa, V., Diaz, F. J., Torrelo, A., Alfaro-Rubio,

A., & Kutzner, H. (2017). Cherry hemanginomas and lipomas with peculiar distribution.

Journal of the American Academy of Dermatology. 76(6). DOI:

https://doi.org/10.1016/j.jaad.2017.04.280

© 2021 Walden University Page 2 of 3

Please see attachment for instructions.

ABDOMINAL ASSESSMENT

Subjective:

· CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”

· HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterward.

· PMH: HTN, Diabetes, hx of GI bleed 4 years ago

· Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs

· Allergies: NKDA

· FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD

· Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

· VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs

· Heart: RRR, no murmurs

· Lungs: CTA, chest wall symmetrical

· Skin: Intact without lesions, no urticaria

· Abd: soft, hyperactive bowel sounds, pos pain in the LLQ

· Diagnostics: None

Assessment:

· Left lower quadrant pain

· Gastroenteritis

Plan: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.

2. Analyze the objective portion of the note. List additional information that should be included in the documentation.

3. Is the assessment supported by subjective and objective information? Why or why not?

4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

5. Would you reject/accept the current diagnosis? Why or why not?

6. Identify three possible conditions that may be considered as a differential diagnosis for this patient ( consider diverticulitis, colitis, appendicitis). Explain your reasoning using at least five different references from current evidence-based literature. The paper has to be write in APA format.

Please see attachment for instructions.

Episodic/Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race


S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.


O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)


A

.

Differential Diagnoses (list a minimum of 5 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.


P.
  

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least five evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

© 2021 Walden University, LLC

Page 1 of 3

Please see attachment for instructions.

Week 5: Assessment of Head, Neck, Eyes, Ears, Nose and throat.

CASE STUDY 1: Focused Nose Exam

Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. As you check his ears and throat for redness and inflammation, you notice him touch his fingers to the bridge of his nose to press and rub there. He says he’s taken Mucinex OTC the past 2 nights to help him breathe while he sleeps. When you ask if the Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal. Richard is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow, but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous.

your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.

About the case study, you have selected:

· Review this week’s Learning Resources and consider the insights they provide.

· Consider what history would be necessary to collect from the patient.

· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. and justify why you selected each.

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources.

Provide evidence from the literature to support diagnostic tests that would be appropriate for each case (at least 5 up to dates references ).

Please see attachment for instructions.

Assignment week 4

Differential Diagnosis for Skin Conditions

The Lab Assignment

· Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.

· Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.

Use this

Picture #4

SOAP must be fabricated.

Attached you can find the template to guide the job.

Use this history if you want and, add details.

”66 years old Hispanic patient present to ER with lower leg redness he noticed in the last 4 days ago. Right leg has erythema with some scaling measuring 15 cm X 12 cm. The are is swollen and appear warm to touch. The difference in the calf size with respect to the other calf is 0.8 cm.

Most Likely diagnosis : Cellulitis. Diffuse, acute, infection of the skin and subcutaneous tissue
caused by: Majority of cases caused by Streptococcus pyogenes or Staphylococcus aureus.

Why?

Differential diagnosis: Must be used and explained.

Acute lipodermatosclerosis

Contact dermatitis

Ectasis dermatitis

Eczematous dermatitis

References must be use. Add more to complete 5 updated references.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.Chapter 9, “Skin, Hair, and Nails”

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.

· Chapter 6, “The Skin and Nails”

The Red Legs RATED tool to improve diagnosis of lower limb cellulitis in the emergency department (attached)

Please see attachment for instructions.

LOWER LIMB CELLULITIS

British Journal of Nursing 2021, Vol 30, No 12: TISSUE VIABILITY SUPPLEMENT PBS22 British Journal of Nursing 2021, Vol 30, No 12: TISSUE VIABILITY SUPPLEMENT

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The Red Legs RATED tool to improve
diagnosis of lower limb cellulitis
in the emergency department

C
ellulitis is a common medical condition that presents
as an acute inflammation of the skin and subcutaneous
tissue, usually as a result of bacterial infection, and
cellulitis of the lower limb is often referred to as a

‘red leg’. It can be a difficult diagnosis to make because it has
many differential diagnoses that result in similar presentations
of red, warm, painful swollen limbs. There are no definitive
diagnostic tests to confirm cellulitis; diagnosis is made based
on clinical evaluation with evaluation of inflammatory marker

results (Quirke et al, 2017; Santer et al, 2018; Sullivan and de
Barra, 2018; Patel et al, 2019a; Patel et al, 2019b; Teasdale et al,
2019). Cochrane reviews (Kilburn et al, 2010; Dalal et al, 2017)
have indicated a dearth of evidence-based guidelines with few
reported clinical trials addressing the difficulties encountered by
clinicians in making an accurate diagnosis, preventing recurrence
and the impact on patients who suffer from red leg syndromes.

It is estimated that 30% of patients presenting with red legs
are often inappropriately admitted to hospital (Levell et al, 2011;
Wingfield, 2012; Yarbrough et al, 2015; Jain et al, 2017;Weng et
al, 2017; Patel et al, 2019b; Edwards et al, 2020).This results in
inappropriate use of antibiotics and delays in diagnosis, which
are costly for both the patient and service provider (Raff and
Kroshinsky, 2016; Weng et al, 2017).. Often the risk factors for
cellulitis such as chronic oedema or tinea pedis/athlete’s foot
are not recognised or treated, exposing the patient to recurrent
episodes of cellulitis. Inappropriate or untreated cellulitis can
lead to severe complications ranging from sepsis to tissue
necrosis and even death (Stevens et al, 2014).

Although international guidelines pertaining to cellulitis
exist (Clinical Resource Efficiency Support Team (CREST),
2005; Stevens et al, 2014; National Institute for Health and Care
Excellence (NICE), 2019) there are no national guidelines in
the Irish Healthcare service. Thus, clinicians are faced with a
dearth of updated clinical evidence and diagnostic strategies or
tools to guide clinical decisions to accurately identify, admit and
treat patients presenting with cellulitis. This poses a challenge in
differentiating cellulitis from other conditions (Wingfield, 2012;
Elwell, 2015; Patel et al, 2019b). The potential misdiagnosis is
due to presenting symptoms such as red, warm, tender or painful
skin, which can also be symptoms of other inflammatory skin
conditions such as stasis dermatitis or lipodermatosclerosis, or
of acute venous issues such as deep venous thrombosis, oedema,
irritant contact dermatitis or vasculitis (Hirschmann and Raugi,
2012a; 2012b).

This presents problems in clinical practice. For example,
patients with chronic lower limb oedema are often admitted
with a diagnosis of bilateral cellulitis and prescribed antibiotics.
The redness and swelling frequently resolves with bed rest,
resulting in early discharge with the assumption that the cellulitis
has responded to the antibiotics. However, this cohort of patients
are frequently readmitted with recurrence of symptoms, which
is then assumed to be failure to respond to treatment and they
are recommenced on stronger antibiotics (Quirke et al, 2017).
Often these patients had improved during the initial admission
due to bed rest and elevation as they have underlying conditions
such as chronic venous insufficiency or congestive heart failure,
which cause lower limb swelling leading to redness and pain.

ABSTRACT
Background: Lower limb cellulitis poses a significant burden for the Irish
healthcare system. Accurate diagnosis is difficult, with a lack of validated
evidence-based tools and treatment guidelines, and difficulties distinguishing
cellulitis from its imitators. It has been suggested that around 30% of
suspected lower limb cellulitis is misdiagnosed. An audit of 132 patients
between May 2017 and May 2018 identified a pattern of misdiagnosis in
approximately 34% of this cohort. Objective: The aim of this pilot project
was to develop a streamlined service for those presenting to the emergency
department with red legs/suspected cellulitis, through introduction of the
‘Red Leg RATED’ tool for clinicians. Method: The tool was developed and
introduced to emergency department clinicians. Individuals (n=24) presenting
with suspected cellulitis over 4 weeks in 2018 were invited to participate in
data gathering. Finally, clinician questionnaire feedback regarding the tool
was evaluated. Results: Fourteen participants consented, 6 female and 8
male with mean age of 65 years. The tool identified 50% (n=7) as having
cellulitis, of those 57% (n=4) required admission, 43% (n=3) were discharged.
The remainder who did not have cellulitis (n=7) were discharged. Before
introduction of the tool, all would typically have been admitted to hospital
for further assessment and management of suspected lower limb cellulitis.
Overall, 72% (n=10) of patients who initially presented with suspected
cellulitis were discharged, suggesting positive impact of the tool. Clinician
feedback suggested all were satisfied with the tool and contents. Conclusion:
The Red Leg RATED tool is user friendly and impacts positively on diagnosis
treatment and discharge. Further evaluation is warranted.

Key words: Lower limb cellulitis ■ Red leg ■ Cellulitis mimics
■ Diagnostic aids

Gillian O’Brien, Registered Advanced Nurse Practitioner
Tissue Viability, Naas General Hospital, Naas, County Kildare,
gillian.obrien@hse.ie

Patricia White, Research Fellow, Trinity Centre for Practice and
Healthcare Innovation, School of Nursing and Midwifery, Trinity
College Dublin

Accepted for publication: January 2021

LOWER LIMB CELLULITIS

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Once they go home this swelling often reoccurs as the patients
either are not resting or do not elevate their limbs. These
underlying chronic conditions require appropriate management
in order to prevent inappropriate hospital admission. Failure to
recognise, address and educate both clinicians and patients about
these chronic complex conditions will result in future multiple,
potentially avoidable admissions (Quirke et al, 2017). Following
a systematic review and meta-analysis considering risk factors
for non-purulent cellulitis, Quirke et al (2017) recommended
that clinicians should address modifiable risk factors, such as
wounds, ulcers, lower limb oedema and toe-web intertrigo.

Quirke et al (2017) examined the challenges and facilitators
in diagnosing lower limb cellulitis, reporting a lack of good-
quality tools or criteria for diagnosing lower limb cellulitis.
They also recommended that future research should examine
from a qualitative perspective the challenges faced by both
clinicians and patients when presented with diagnostic
dilemmas pertaining to cellulitis and its mimickers. As no exact
diagnostic test for cellulitis exist, clinicians rely on their clinical
experience and interpretation of results such as inflammatory
blood markers. This, coupled with the absence of clear national
guidelines, can potentially lead to misdiagnosis or over diagnosis
of severity of infection (Hirschmann and Raugi, 2012b)
resulting in:

■ Inappropriate antibiotic use in an era of rising antibiotic
resistance

■ Prolonged length of hospital stay
■ Recurrence due to mismanagement
■ Failure to manage the true diagnosis
■ Poor patient outcomes
■ Misuse of finite resources.

Strategies are needed to reduce unwarranted variation in care
with a focus on resourcing care that benefits the patient in line
with Ireland’s Health Service Executive (HSE) ethos of right
care by the right person, in the right place at the right time. An
Irish study audited antibiotic use in patients admitted with skin
and soft tissue infections in an Irish hospital setting (Kiely et al,
2020), and the authors suggested that adherence to international
guidelines would significantly reduce unnecessary admission,
avoid over consumption of unnecessary antibiotics and improve
antimicrobial stewardship. UK research has reported similar
findings (Elwell, 2015; Weng et al, 2017; Patel et al, 2019b).
A UK alliance was established including both patients and
practitioners to establish research priorities pertaining to cellulitis
with particular focus on the qualitative aspects associated with
clinicians and diagnosing appropriately and patient experience
(Thomas et al, 2017).

Improving management of patients
presenting with ‘red leg’
The first author is employed as a Registered Advanced Nurse
Practitioner (RANP) in tissue viability and dermatology
in an acute hospital setting in Ireland. This article describes
a recent RANP-led pilot project that involved the
introduction of a ‘Red Leg RATED’ tool streamlining the
process for patients presenting to an emergency department
with suspected lower limb cellulitis, by showing information
on differential diagnosis or imitators of cellulitis.

Data extracted from the hospital inpatient enquiry system
system reported 132 inpatient admissions with a diagnosis
of lower limb cellulitis between May 2017 and May 2018.
Associated length of stay exceeded 1200 days with a mean
length of stay reported as 9.16 days at a cost of €1 038 531,
excluding associated costs of consumables or antibiotics. Per
patient admitted it costs approximately €10 000 per stay. A
retrospective chart review suggested that approximately 34%
of those were misdiagnosed with cellulitis and potentially
could have been discharged with outpatient management and
RANP follow-up care. Recognising these data, the potential
misdiagnosis of cellulitis and issues in clinical practice, the
RANP in collaboration with an expert group proposed the
development of a tool to assist clinicians in the diagnosis
and subsequent management of cellulitis, or in forming a
differential diagnosis. Further, a pilot project would seek to
evaluate the use of a tool in identifying cellulitis versus a
differential diagnosis and appropriately managing cellulitis in
a cohort of patients presenting to the emergency department.
Additionally, clinician feedback of the tool in clinical practice
would be evaluated.

The overarching aim of the proposed pilot project was to
develop a streamlined service facilitated through use of the
tool that fulfils the ‘right person, right place, right time, and
right team’ ethos underpinning the Irish healthcare service in
diagnosing and appropriately treating suspected cellulitis in an
emergency department.

Methods
Ethical approval
Ethical approval was granted from the hospital ethics
committee to undertake a 4-week pilot study in August 2018.
All identified potential participants (n=24) were informed of
the study through a gatekeeper and 14 (58%) consented.

Expert group
An expert group was formed in June 2018 (Box 1). The
premise of the expert group was to develop a tool to improve
diagnostic accuracy of lower limb cellulitis, identify possible
differential diagnosis and put in place a plan of care to manage
the conditions diagnosed. An exhaustive list of potential
differential diagnoses was considered inappropriate; the top
differential diagnoses as identified in literature as imitators of
cellulitis were chosen to be included in the tool.

Collaboratively, a management care pathway was included
for each potential differential diagnosis with provision
for RANP outpatient follow-up for patients whom were
discharged home to ensure re-evaluation of their condition.
Guidance was also included in the tool pertaining to criteria

Box 1. Key stakeholders in the Red Leg expert group

■ Advanced nurse practitioner tissue viability/dermatology x 1
■ Dermatology consultant x 2
■ Emergency medicine consultant x 2
■ Vascular consultant x 1
■ General surgeon x 1
■ Microbiologist x 1
■ Antimicrobial stewardship pharmacist x 1
■ Research support provided by a post-doctoral researcher and
an academic from a partnering university

LOWER LIMB CELLULITIS

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for admission, suitability for outpatient services and alerts for
serious conditions such as necrotising fasciitis, with links to
local prescribing guidelines for skin and soft tissue infections
(Figure 1).

Red Legs RATED tool development
The development of the Red Legs RATED tool occurred
using a Plan Do Study Act (PDSA) cycle, incorporating
expert feedback, staff education, a pilot phase and evaluation
of ease of use of the tool with user feedback. The Red Leg
RATED tool included descriptive criteria and images for
the identification of cellulitis with recommendations for
management and follow-up.

Education
Prior to use of the Red Leg RATED tool education sessions
were planned with all emergency department staff over a
4-week period beginning in July 2018. Clinicians, specifically
non-consultant hospital doctors, consultants, RANPs and
nursing staff were provided with interactive face-to-face
education sessions with support from the RANP in tissue
viability and the emergency department consultants. A folder
was made available for all emergency department staff with
educational support in use of the tool.

Retrospective chart review
A medical chart review of those who presented with red legs

and suspected cellulitis over the 4 weeks was undertaken to
ascertain diagnosis, management and follow-on care.

Post-pilot questionnaire
A brief questionnaire assessed user-friendliness of the tool as
an aid to diagnosis following a 4-week pilot use of the newly
developed and implemented Red Leg RATED tool.

Results
Fourteen (58%) of those patients presenting with red legs
agreed for their data to be included. Of those, 43% (n=6) were
female and 57% (n=8) were male with an overall mean age
of 65 years. The Red Leg RATED tool identified 50% (n=7)
true diagnosis of cellulitis, of those 57% (n=4) required hospital
admission, 43% (n=3) were discharged. This discharge cohort
is typically admitted to hospital for further assessment and
management of suspected lower limb cellulitis. The remaining
50% (n=7) were found not to have cellulitis and discharged
to expert RANP follow-up. The referral was warranted
in all cases. Overall, 72% (n=10) of patients (consenting to
inclusion) who presented with suspected cellulitis and would
typically have been admitted to hospital were discharged. Of
the completed clinician questionnaire (n=13), 100% of users
were satisfied with the tool and contents, found it easy to
use and felt it helped them make a more accurate diagnosis
of cellulitis versus a differential diagnosis. All users agreed the
education prior to using the tool was appropriate and the tool

Figure 1. Sample of differential diagnosis of suspected cellulitis

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useful and of clinical benefit; 92% (12/13) reported that the
tool contained the right amount of information while one
respondent stated that there was too much information.

Qualitative analysis suggests all (n=13)of the non-
consultant hospital doctors and RANPs who used the
tool reported that the education they received was clear,
comprehensive and helpful. The tool was described as ‘an
extremely sophisticated tool which offers a clear pathway
for diagnosing patients’. It was described by one clinician as
‘a fool-proof guide to managing (red leg) presentations’. Its
value in avoiding unnecessary admissions was also noted. Box
2 reflects some of the feedback comments.

Between May 2017 and May 2018, 132 patients
were admitted to hospital with suspected cellulitis with
34% possible misdiagnosis. After the pilot project, which
demonstrated the benefits of the tool, it became widely
used within the emergency department setting—research is
underway into the impact of this. A retrospective chart review
and early data analysis suggests that within a 1-year timeframe,
September 2018 to September 2019, the admission rate for
cellulitis has decreased considerably. In that 1 year the tool was
used with 177 patients who presented with red leg-suspected
cellulitis, only 37% (n=66) patients were admitted to hospital,
all were appropriately admitted. Of those discharged, only
29% (n=51) required referral to the RANP outpatient clinic
for follow up regarding a differential diagnosis. The remaining
34% (n=60) were discharged to general practitioner follow-up.

Discussion
The Red Leg RATED tool seems to have benefits for both
clinicians and the organisation with aid to diagnosis and
potentially avoiding inpatient admissions and the associated
costs with appropriate management and follow-up of care. Over
a 4-week timeframe the pilot project demonstrated a potential
cost saving of €100 000 with no requirement for hospital
admission. The tool is user-friendly and has impacted positively
on the diagnosis and treatment of cellulitis. Further research
and evaluation of the tool is ongoing to determine diagnostic
validity in a larger cohort and over a longer timeframe.
Future research is planned with the aim of understanding the
challenges patients face when presenting with red leg symptoms
(red, warm, painful legs) and what effects these, and the various
conditions that can cause them, have on the patient.

Limitations
The pilot study has limitations as it was undertaken in an acute

adult ED of a general hospital that may not be representative
of the wider population. The tool is only available in hard
copy format. Data collection was also in hard copy format
and was dependent on clinicians entering the data. Therefore,
the full population of potential participants may not have
been captured. This was particularly applicable for patients not
admitted to hospital as these are not captured on the hospital
inpatient enquiry system data system.

Future steps
The pilot study has provided impetus to explore the full
potential impact of the tool. Subsequently, an alert system was
added to the emergency department information technology
system to use the tool if patients were presenting with red legs
and suspected cellulitis. It is anticipated that this future research
will be reported as a follow up to this pilot study.

Conclusion
Cellulitis can be difficult to diagnose but the application of
the Red Legs RATED Tool in emergency care and supportive
education can benefit patients, clinicians and the organisation.
Improved management and prescribing practices particularly
with regard to antimicrobial stewardship in an era of rising
global antibiotic resistance is pivotal. Improved use of finite
healthcare resources and improved patient outcomes all
underpin the impetus to further explore this area of research
and the reported results supports the impetus to validate the
tool at a wider level. BJN

Declaration of interest: none

Acknowledgement: The authors wish to acknowledge the work and
support of the Red Leg expert group (Professor Anne-Marie Tobin
Consultant Dermatologist, Clinical Lead Dermatology, Dr Asad Salim
Consultant Dermatology, Dr George Little Consultant Emergency
Department, Dr Mary Kerins Consultant Emergency Department,
Mr Emmanuel Eguare Consultant General Surgeon, Professor Sean
Tierney Consultant Vascular Surgery, Dr Gerome Fennell Consultant
Microbiologist, Dr Sarah Bergin Consultant Microbiologist, Pauline
Duggan Antimicrobial Pharmacist ) and Dr. Patricia Cronin of the
School of Nursing and Midwifery, Trinity College Dublin for her
academic support.

Funding: This research was part supported by funding from the
Dublin South, Kildare and Wicklow National Midwifery Planning
Development Unit

Clinical Resource Efficiency Support Team. Guidelines on the management of
cellulitis in adults. 2005. https://tinyurl.com/3bapk3pt (accessed 9 June 2021)

Dalal A, Eskin-Schwartz M, Mimouni D, Ray S, Days W, Hodak E, Leibovici L,
Paul M. Interventions for the prevention of recurrent erysipelas and cellulitis.
Cochrane Database Syst Rev. 2017;6(6):CD009758

Edwards G, Freeman K, Llewelyn MJ, Hayward G. What diagnostic strategies can
help differentiate cellulitis from other causes of red legs in primary care? BMJ.
2020:368:m54. https://doi.org/10.1136/bmj.m54

Elwell R. Developing a nurse-led ‘red legs’ service. Nurs Older People. 2015
26;27(10):23–27. https://doi.org/10.7748/nop.27.10.23.s20

Hirschmann JV, Raugi GJ. Lower limb cellulitis and its mimics: part1. Lower limb
cellulitis. J Am Acad Dermatol. 2012a;67(2):163.e1-12.

Hirschmann J.V and Raugi G.J. (2012b) Lower limb cellulitis and its mimics:
part II. Conditions that simulate lower limb cellulitis.J Am Acad Dermatol.
2012b;67(2):177.e1-9. https://doi.org/10.1016/j.jaad.2012.03.023.

Jain SR, Hosseini-Moghaddam SM, Dwek P et al. Infectious diseases specialist

Box 2. Clinician feedback comments

■ Photos of relevant differentials were great and taught me a lot I didn’t know about
Red Leg

■ Education prior to using the tool was very comprehensive and helpful; much
appreciated

■ Really good training initially. Maybe a follow-up would be helpful
■ Very helpful with really clear advice/criteria for admission
■ Good to have guideline on who to admit and who not requiring admission
■ Photos of relevant differentials were great and taught me a lot I didn’t know about
Red Leg

■ Good guidance with clear pictures. Tick box criteria for cellulitis very helpful feels
like, coupled with my experience I now have a fool-proof guide to managing the
presentation, thank you!

LOWER LIMB CELLULITIS

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management improves outcomes for outpatients diagnosed with cellulitis in
the emergency department: a double cohort study. Diagn Microbiol Infect Dis.
2017;87(4):371–375. https://doi.org/10.1016/j.diagmicrobio.2016.12.015

Kiely A, Elwahab SA, McDonnell D et al. Over-admission and over-treatment of
patients with cellulitis: a 5-year audit against international guidelines. Ir J Med
Sci. 2020;189(1):245-249.https://doi.org/ 10.1007/s11845-019-02065-w

Kilburn SA, Featherstone P, Higgins B, Brindle R. Interventions for cellulitis and
erysipelas. Cochrane Database Syst Rev. 2010;2010(6):CD004299.

Levell NJ, Wingfield CG, Garioch JJ. Severe lower limb cellulitis is best diagnosed
by dermatologists and managed with shared care between primary and
secondary care. Br J Dermatol. 2011;164(6):1326–1328.

National Institute for Health and Care Excellence. Cellulitis and erysipelas:
antimicrobial prescribing. NICE guideline NG141. 2019. https://www.nice.
org.uk/guidance/ng141 (accessed 14 June 2021)

Patel M, Lee SI, Thomas KS, Kai J. The red leg dilemma: a scoping review
of the challenges of diagnosing lower‐limb cellulitis. Br J Dermatol.
2019a;180(5):993–1000. https://doi.org/10.1111/bjd.17415

Patel M, Lee SI, Akyea RK et al. A systematic review showing the lack of
diagnostic criteria and tools developed for lower‐limb cellulitis. Br J Dermatol.
2019b;181(6):1156–1165. https://doi.org/10.1111/bjd.17857

Quirke M, Ayoub F, McCabe A, Boland F, Smith B, O’Sullivan R, Wakai A. Risk
factors for nonpurulent leg cellulitis: a systematic review and meta-analysis. Br J
Dermatol. 2017;177(2):382–394. https://doi.org/10.1111/bjd.15186

Raff AB, Kroshinsky D. Cellulitis. JAMA. 2016;316(3):325–337. https://doi.
org/10.1001/jama.2016.8825

Santer M, Lalonde A, Francis NA et al. Management of cellulitis: current practice
and research questions. Br J Gen Pract. 2018 Dec;68(677):595–596. https://
doi.org/10.3399/bjgp18X700181

Stevens DL, Bisno AL, Chambers HF et al for Infectious Diseases Society of
America. Practice guidelines for the diagnosis and management of skin and soft
tissue infections: 2014 update by the Infectious Diseases Society of America.
Clin Infect Dis. 2014;59(2):e10–e52. https://doi.org/10.1093/cid/ciu296

Sullivan T, de Barra E. Diagnosis and management of cellulitis. Clin
Med (Northfield Ill). 2018;18(2):160–163. https://doi.org/10.7861/
clinmedicine.18-2-160

Teasdale EJ, Lalonde A, Muller I et al. Patients’ understanding of cellulitis and views
about how best to prevent recurrent episodes: mixed‐methods study in primary
and secondary care. Br J Dermatol. 2019;180(4):810–820.

Thomas KS, Brindle R, Chalmers JR et al. Identifying priority areas for research
into the diagnosis, treatment and prevention of cellulitis (erysipelas): results

of a James Lind Alliance Priority Setting Partnership. Br J Dermatol.
2017;177(2):541–543. https://doi.org/10.1111/bjd.15634

Weng QY, Raff AB, Cohen JM et al. Costs and consequences associated with
misdiagnosed lower extremity cellulitis. JAMA Dermatol. 2017;153(2):141–
146. https://doi.org/10.1001/jamadermatol.2016.3816

Wingfield C. Diagnosing and managing lower limb cellulitis. Nurs Times.
2012;108(27):18–21

Yarbrough PM, Kukhareva PV, Spivak ES, Hopkins C, Kawamoto K. Evidence-
based care pathway for cellulitis improves process, clinical, and cost outcomes. J
Hosp Med. 2015;10(12):780–786. https://doi.org/10.1002/jhm.2433

KEY POINTS
■ The introduction of a Red Leg RATED Tool in the emergency department assists
clinicians in accurately diagnosing and treating lower limb cellulitis versus a
differential diagnosis

■ It assists clinicians in diagnosis and management through its ease of use
■ It facilitates accurate diagnosis and management thereby reducing hospital
admissions and associated costs

■ Also facilitates follow up by an Registered Advanced Nurse Practitioner in tissue
viability through a specific referral process contained in the tool

CPD reflective questions
■ How would you ensure accurate diagnosis and correct management of
lower limb cellulitis?

■ What do you think are the potential differential diagnoses and
appropriate investigations when patients present with red legs to the
emergency department?

■ How could you empower patients to recognise symptoms sooner in
order to avoid hospital admission?

Copyright of British Journal of Nursing is the property of Mark Allen Publishing Ltd and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder’s express written permission. However, users may print, download, or email
articles for individual use.

Please see attachment for instructions.

Week 8 post.

Case 1: Back Pain

A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg.

In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved?

How would you test for each of them?

What other symptoms need to be explored?

What are your differential diagnoses for acute low back pain?

Consider the possible origins of using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework.

What physical examination will you perform? What special maneuvers will you perform?

Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template

Consider what history would be necessary to collect from the patient in this case study

Provide evidence from the literature to support diagnostic tests that would be appropriate for each case.

List five different possible conditions for the patient’s differential diagnosis and justify why you selected each. 

Please see attachment for instructions.

Episodic/Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race


S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.


O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)


A

.

Differential Diagnoses (list a minimum of 5 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.


P.
  

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least five evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

© 2021 Walden University, LLC

Page 1 of 3

Please see attachment for instructions.

• CHAPTER

24 Low Back Pain (Acute)
A report of acute low back pain (ALBP),
~}though quite common, requires a thor­
ough evaluation. The underlying pathophysi­
o logy of back pain is frequently multifactorial
and includes both physiological and psy­
chological components . The most common
causes ofALBP relate to musculoligamentous
injuries and age-related degenerative pro­
cesses. A bout 90% of ALBP episodes in
adults are related to mechanical causes that
resolve within 4 weeks without serious se­
quelae. A smaller percentage of patients will
continue to have chronic symptoms without
organic pathology or have underlying disease.

In chi ldren, the prevalence of back pain
increases with age and with involvement in
sports. Anthropometric variations in children
place them at risk for excess strain on the
spine, producing back pain. These variations
include reduced hip mobility, decreased lum­
bar extension and increased lumbar flexion ,
poor abdominal muscle strength, tight ham­
string muscles, and lumbar hyperlordosis.

Acute low back pain is defined as activity
intolerance producing lower back or back­
related leg symptoms of less than 3 months ‘
duration. The Agency for Healthcare Research
and Quality (AHRQ) guidelines provide
the fo llowing framework for causes of
ALBP:
• Potentially serious conditions (e.g., spinal

fracture, tumor, infection, or cauda equina
syndrome)

• Sciatica, or leg pain and numbness of the
lateral thigh, leg, and foot, suggesting
nerve root compression (Fig. 24. I)

• Nonspecific back problems such as mus­
culoskeletal strain, diskogenic pain, or
bony deformity secondary to inflamma­
tory diseas e

• Nonspinal causes secondary to abdominal
involv~ment (e.g., gallbladder, l iver, renal,

336

pelvic inflammatory disease, prostate
tumor, ovarian cyst, uterine fibroids, aortic
a n eurysm, or thoracic disease)

• Psychological causes such as stress related
to work environment (e.g ., disability,
workers’ compensation, secondary gains).
When evaluating ALBP, the goal of the

clinician is to first identify signs and symp­
toms of potentially serious conditions through
a careful history and physical examination. A
holistic approach to the patient is needed to
appreciate the extent to which pain affects the
patient’ s daily routine or work- related activi­
ties. Because ALBP is a common occupation­
related complaint and a cause of disability
and lost productivity, the clinician must gain
insight into the patient’s psychosocial and
economic situation to help arrive at a correct
diagnosis.

DIAGNOSTIC REA s n.:. )NG: FOCUSED
HISTORY

Is this a potentially serious cause ofALBP?

Key Questions
• Do you have a fever?
• Have you experienced any trauma to the

spine or back?
• Do you have any other health problems?
• Have you b een treated for cancer?
• What is your age?
• Have you had loss of control of your

bowels or bladder?
• Are you taking any medications?

Fever
The pre sence of a fever indicates an inflamma­
tory condition such as spondyloarthropathy or
systemic infection. Infection is a likely diag­
nosis when there are chills and fever, weight
loss, a recent history of bacterial infection,

Chapter 24 • Low Back Pain (Acute}

Nerve root

Pain

Numbness

Motor

weakness

Screening

examination

Reflexes

f.1GURE 24.1 Testin g for lumbar nerve root compromise. (From Bigos S, Bowyer OR, Braen GR, et a l : A c ute
/ow back problems in adults, clinical practice guidelines, Quick Reference Guide Number 14, Rockville ,
~d., 1994, Department of Health and Human Services, U.S. Public H ea lth Service, Age ncy for H ealt h Care
Policy and Research, AHCPR Publication No. 95-0643.)

L4 LS S1

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t
I
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I
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I
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I ;’

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I

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I )~
J

! ;. /I I
I
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J
I

Extension of Dorsiflexion of Plantar flexion
quadriceps great toe and of great toe

foot and foot

Squat and rise Heel walking W a lking on
toes

Knee jerk None reliable Ankle jerk
diminished diminished

Jntravenous drug use, or immunosuppression.
Ewing sarcoma is a malignant tumor and can
mimic spinal infection, occu rring as back pain
that can be accompanied by fever. Children
~ith discitis will h ave a fever and refuse to
~alk because of back pain. In adu lts, vertebral

steomyel iti s or disciti s occurs mos t ofte n as a
esult of h ematogenou s seedi n g of S. aure us,
troduced through invasive procedures or

urgery. Pain localizes over the infected disc
rea and is made worse with physical activity.

Pain may radiate to the a bdomen, leg, scro­
tum , gro in, or perineum.

Trauma
Acute trauma to the spinal cord can result
in fracture, dislocation, or damage to muscles,
ligaments, and intervertebral disks. Trauma
may be cau sed by blunt impact, repetitive in­
jury, or s udden str ess caused by lifting or
pulling. Low back p a in is the most common
occupational injury reported, so knowing a

Chapter 24 • Low Back Pain (Acute)

patient’s occupation helps assess specific risk
factors. Injury to the back usua]]y results in
contusions and abrasions but can a]so cause
spinal fracture if the force is major, such as
that sustained in a motor vehicle accident or
fa]J. Adults can have an acute compression
spinal fracture as a result of strenuous lifting
when osteoporosis is present. Most cases of
ALBP in adolescents who are athJeticaHy ac­
tive are caused by injury to the posterior
structures of the spine.

Injury to the spinal column should be
suspected in anyone whose level of con­
sciousness is impaired after an accident.
Cervical , thoracic and lumbar spine fractures
are sustained during flexion, extension, com­
pression, rotation, or a combination of forces.

Systemic Disease and Cancer
Metabolic disease , inflammatory disorders,
and fibromyalgia can lead to back pain.
Patients with a history of cancer may have
increased risk of a metastatic spinal tumor.
Neuroblastoma is common in young chil­
dren , and although it occurs in the abdomen,
metastases to the spine may produce back
pain. People younger than 20 years and
older than 50 years are at increased risk for
tumor, as are those with a history of cancer.

Age
In the absence of trauma, the sudden onset of
severe low or middle back pain in people older
than 30 years might suggest a dissecting aortic
aneurysm; the pain is not alleviated by rest.
Patients older than 50 years are at increased
risk for compression fracture as we11 as cancer.

Bowel and Bladder Sy mptoms
Loss of urinary or stool c o ntinence are early
s igns of conus rnedulari s syndrome (verte bral
involve ment at L2) and late signs of cauda
equina s yndrome which involv e s nerve root
compromise in the lower lumbar and sacral
nerve roots secondary to a herniate d disk, nerve
root entrapment, spinal stenosis, infection, or
tumor. Cauda equine is considered a surgical
emergency. Other symptoms include constant
lumbar pain with saddle anesthesia, urinary
retention or overflow incontinence, and fecal
incontinence due to an atonic anal sphincter.

Cauda equina
Children are embarrassed to talk about urj.
nary or bowel habits and changes . Hidder
spinal cord tumors might have a relation.
ship to deve l opmental delays in bladde1
and bowel control. Children younger than
4 years of age who have back pain should be
evaluated for serious diseases, such as intra­
spinal tumors , dermoid cysts, and malignant
astrocytomas.

Medications
Long-term use of corticosteroids can lead to
compression fractures of the vertebrae. Use
of intravenous drugs may suggest infection as
a cause.

What does the location ofpain tell me?

Key Question
• Where does it hurt?

Location of Pain
In general, children are less specific than adults
when describing location of pain. Traumatic
lesions are more likely to occur in the cervical
and lumbar portions of the spine, where there
is more motion and less protection. General­
ized pain or pain over a fairly wide anatomical
area is frequently seen with overuse problems
and inflammatory conditions.

Sciatica pain is a sharp, burning pain that
radiates down the posterior and lateral leg to
the foot or ankle . Rheumatoid arthritis pro­
duces pain in the upper back and neck. Local­
ized pain is seen with spondylolysis and
tumors. Flank pain in adults may indicate a
kidney infection. Pain from gallbladder disease
radiates to the subscapular areas. Compression
fractures of vertebrae associated with osteopo­
rosis or malignancy may produce pain over
the area where the fracture has occurred.

Chi ldren with traumatic low back derange­
ment will have pain and muscle spasm in the
lumbar area from the shock ofan impact injury.

What does the pattern ofpain t ell me?

Key Questions
• When did the pain start?
• How long have you had this pain?

Chapter 24 • Low Back Pain (Acute)

What does the pain feel like?
• Does it interfere with s leep?
• Ha e you had this pain before?

onset
The onset of ALBP is sudden, and more than
half of patients do not associate it with a spe­
cific precipitating event or injury. The vast
majority of cases of ALBP resolve with con­
servative treatment in 4 weeks, and radio­
graphic or further diagnostic studies are not
recommended unless it associated with
trauma or symptoms such as radiating pain to
an extremity, extremity weakness or bladder
or bowel dysfunction.

Children are frequently poor historians,
and parents may have a difficult time remem­
bering when the pain started. Association with
events such as birthdays, holidays, and activi­
ties is helpful in establishing the onset of
a child’s pain. Mild pain of short duration
(1- 2 weeks) is rarely serious.

Back pain lasting longer than 4 weeks needs
to be reevaluated for further diagnostic studies.

Duration
Subacute back pain is of 6 to 12 weeks’ dura­
tion. Chronic back pain is pain lasting for
more than 3 months. In people younger than
40 years of age, the cause may be postural,
related to weak abdominal or back muscles,
or may indicate congenital spinal deformity,
such as scoliosis or ankylosing spondylitis. In
older people, chronic back pain is more likely
to indicate degenerative disease, such as spi­
nal stenosis or disk herniation. In children,
back pain present for more than 3 weeks is
often caused by organic and serious causes.

Pain Characterist ics
lo chi ldren, express ion of pain depends on the
child’s ability to put feelings of pain into
behavior; observing for these behaviors is
important. Ask childr en to rate the pain using
a IO-point pain s c a le with happy to sad faces
(see Chapter 3 ). A s k adults to rate pain from
0 (no pain) to 10 (worst pain ever) and assess
how much the pain interferes with daily ac­
tivities. Intractable back pain, especially night
pain with constitutional findings, i s li kely to
indicate neoplastic disease. Hyperalgesia is

increased sensitivity to pain in damaged
tissue; this can develop after long-term use
of opioids for chronic pain.

Night Pain
Nighttime back pain is a worrisome symptom
that often signals a serious problem, such as
tumor, infection, or inflammation. Generally,
muscle strains, overuse injuries, spondyloly­
sis, spondylolisthesis, and Scheuermann dis­
ease (an exaggeration of the normal posterior
convex curvature of the thoracic spine) pro­
duce less pain at night. Morning stiffuess
that improves as the day progresses suggests
osteoarthritis or ankylosing spondylitis.

Nighttime back pain is unusual and indicates
the need for a complete and thorough workup.

Recurring Pain
Back pain in young children who have had
previous injuries or fractures may be a symp­
tom of child abuse. In older adults, it may be
an indication of compression fractures of the
spine. As with young children, it may also
signal abuse by a caregiver.

What does the pain in relation to activity
tell me?

Ke y Questions
• What makes the pain worse?
• What makes the pain better?
• School children: do you carry a backpack?

Aggravating Factors
Pain in the lumbar area after strenuous sport­
ing activities is usually the result of trauma to
the muscles and tendons, causing contusions
and sprain. It occurs when the patient pushes
the muscles and ligaments past the normal
level of tolerance. Repeated injury can cause
soft tissue scarring and shortening.

Stress and fatigue fractures of the pars in­
terarticularis, the region between the superior
and inferior articulating facets of the vertebra,
occur when lumbar lordosis places more
stress on the pars, such as in gymnastics and
tennis.

Pain that is aggravated by activity is usually
musculoskeletal in origin. Pain of ankylosing
spondylitis is relieved with exercise. Spinal

Chapter 24 • Low Back Pain (Acute)

stenosis is associated with increased pain with
stand.in& sneezing, or coughing. In an active
aduJt, poor preparation before exercise can lead
to back injwy and pain. Severe low back pain is
often the first symptom reported with spinal cord
compression. When pain is not improved with
lying down it suggests cancer or infection. Pain
with movement suggests vertebral instability.

Any child who has voluntarily given up a
pleasurable activity because of back pain has
a severe symptom.

Alleviating Factors
Back pain not associated with any activity and
not relieved by rest may indicate tumor. In
children, back pain relieved with aspirin
or nonsteroidal antiinflammatory drugs may
indicate an inflammatory cause. Pain that is
alleviated by rest and heat indicates a muscu­
loskeletal cause. Pain of spinal stenosis is
relieved by flex ion of the spine.

Suspect spondylolisthesis, or forward slip­
page of one vertebra over another, if the onset
of pain is during hyperextension, which can
occur with a back handspring, butterfly stroke
in swimming, or a tennis serve. The defect
can be the result of degenerative processes in
older patients or arise from a stress fracture or
stress reaction of the isthmus of the pars inter­
articularis in the area of L5 to SI. The pain
localizes to the low back and occurs during a
growth spurt and after engaging in sporting
events. The pain improves with rest and is
worse with standing.

Backpack
School children often cany heavy backpacks,
increasing the risk of b ack pain and injury.

What does radiation of1miu 11:·ll r.u! ?

• Does the pain travel?
• Can you show me where the pain travels?

Radiation of Pain
Referred pain is of two types: (1) pain referred
from the spine into areas lying within the lum­
bar and upper sacral dennatomes and (2) pain
referred from the pelvic and abdomina l
viscera to the spine. Pain from the upper lumbar

spine us ually radiates to the anterior aspects of
the thighs and legs, and pain from the lower
lumbar spine radiates to the gluteaJ regions,
posterior thighs, and calves (see Figure 24.4).

Pain from visceral di sease is us ually felt
within the abdomen or flanks. Gallbladder
pain radiates around the trunk to the right
scapula. Position does not affect the pain.

ln children and adolescent athletes, spondy­
lolysis typically represents a fracture of the
posterior arch in the lower lumbar s pine due to
overuse and is a relatively common cause of
low back pain. Spondylolisthesis, an anterior
displacement of a vertebra, is less common.
Patients often develop pain that spreads across
their lumbar region and radiates into their
buttocks or posterior legs.

Pain that is sharp and burning and radiates
down the lateral or posterior aspect of the leg
to the lateral ankle or foot is called sciatica
and is a classic symptom of nerve root irrita­
tion most often caused by disk herniation.

Are there signs ofneurological damage?

Key Questions
• Have you been stumbling?
• Have you noticed any change m your

balance or coordination?
• Does the child frequently stumble or fall?
• Do you have numbness or tingling in your

extremities?

Stumbling
Spinal cord twnors, such as astrocytoma or epen­
dymoma, may present as a disturbance of move~
ment, posture, or strength in the spine or extremi­
ties . lmpainnent of proprioception or sensation
from an upper motor neuron lesion, exhibited by
foot drop or ataxia, may produce stumbling.

Numbness and Tingling
Radiculopathy (nerve root pain) is sharp pain
fe lt in a dermatomal pattern and is sometimes
a ssociated with numbness and tingling.

ls there a family history of back pain?

Key Question
• Does anyone in your fan1ily have scoliosi

or a crooked spine?

Chapter 24 • Low Back Pain (Acute)

Does Lou• Back Pain in Adolesce11ts2 EVIDENCE-BASED PRACTICE
/11tficllte a Serious Prob/e111?

Astudy of more than 200,000 adolescents who
presented to a health care provider with low back
pain were followed for 1 year. At 1 year, more
than 80% of the adolescents had no identifiable
diagnosis. The most common diagnoses found at

1 year were lumbar sprain-strain, less than 8%;
scoliosis, less than 4 %; and lumbar degenerative
disk disease, less than 1%. Spondylolysis, spon­
dylolisthesis, i nfection, tumor, and fracture had
a less than 1 % association with LBP.

Reference: Yang et al , 201 7.

Family History
Spondylolysis and scoliosis are often seen in
families, with a 40o/o familial occurrence in
Native Alaskans.

Could this pain be caused by systemic
disease?

Key Question
• Have you been ill?

Illness
Pharyngitis or upper respiratory tract infec­
tions, such as pneumonia, can be the precur­
sor to diskitis, inflammation of the vertebral
disk space, in children. The intervertebral
disk in children receives its blood supply
from the surface of the a djacent vertebral
bodies, providing the mechanism necessary
for infection. Uveitis and iritis may be associ­
ated with juvenile rheumatoid arthritis or
juvenile ankylosing s pondylitis.

A female patient with pelvic inflammatory
disease (PID) may h ave mild to moderate dull,
aching, lower abdominal, pelvic, or possibly
back pain. With pyelonephritis, the patient
may report fever, nausea and vomiting, head­
ache, and back or flank pain. A urinary tract
infection may present as back pain.

DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAM INATION
Observe the Patient’s General Appearance
and Behavior
Any person appearing ill with a fever, limp, or
unwillingness to walk is highly suspect for
having an infectious cause of back pain; how­
ever, a number of these symptoms may have

a psychological component that should be
explored.

Observe for symmetry of posture and
movement from direct anterior, posterior, and
lateral views ofthe patient. Note the amount of
thoracic kyphosis (anteroposterior curve) and
lumbar lordosis (anterior convexity) and the
alignment of the head and neck above the
center of gravity. Children with diskitis often
protect their backs by sitting in a hyperex­
tended position, u sing the arms as support, and
may lie down and cry if they are made to sit.

Observe Gait
Shifting or leaning to one side (listing) and
atypical scoliosis may indicate a tumor. List­
ing is caused by asymmetric sustained muscle
contraction. The spinal curvature serves to
relieve the discomfort and reduce pressure on
a nerve root.

Severely affected gait in spondylosis is
caused by hamstring tightness and results in
uneven s tride length with a persistently fixed
knee to prevent hip flexion, which would stretch
the tight hamstring muscles and increase pain.

Assess Vital Signs
Fever may indicate systemic infection as
well as diskitis. Unexp la ined weight loss may
suggest n eoplasm, infection, or depression.

Examine Skin
Dermal cysts or a h a iry patch over the s pine
may indica te spina l a nomaly or tumor.

A doughy, fatty m ass in the midline of the
back (sometimes covered with h air [a Faun
beard]) is evidence of a lipoma, which may
extend into the spi nal cord and produce
n eurologic symptoms.

Chapter 24 • Low Back Pain (Acute)

Examine Eyes, Ears, Nose, and Mouth
Uveitis iritis is seen in juvenile rheumatoid
arthritis and ankylosirtg spondyli tis. P h aryn gi­
tis, otitis media, or infect ion of h ematogenous
origin may be t he cause of diskitis in chi ldren.

Inspect the Back and Extremities
Observe for spinal a lignment and symmetry of
the t ips of the scapula, iliac crests, and g lutea l
crease. If ind icated, measure and compare leg
lengths from the anterosuperior ili ac crest to
th e medial mal leo lus. Measurements can be
performed with the patient standing or sup ine.
Legs should be of equal length or have less
than 1 cm differen ce in length. Leg length dif­
ferences are associated with pathologic condi­
tions of the sacroiliac, facet joint, and disk.

From posterior and lateral viewpoints,
observe the patient bending forward with feet
together to detect scoliosis, kyphosis, or stiff­
ness and guarding.

Percuss and Palpate Back and Spine
Painful scoliosis and stif:llless are common in
osteoid osteoma. I diopathic scoliosis is usu­
a lly painless without functional limitation .
Point tenderness over the affected area is a
finding associated with a compression fracture
of the vertebrae or an infection of the spin e.

Palpate and percuss the back to determine
if tenderness is in the paravertebral muscular
or midline spinou s processes, which may

indicate diskitis or osteomyelitis. To rule out
the sacroi li ac joint as the si te of origin of
ALBP, cond~ct ~ FABER . test (~ig. 24.2).
Place the patient m the supme pos itio n . Flex
the leg and put the foot of the tested leg on the
opposite knee. The motion is that of tlexion
abduction , external rotation at the hip. Slow1;
press down on the superior aspect of the
tested knee joint lowering the leg into further
abduction. The test result is positive if there is
pain at the hip or sacral joint or if the leg can­
not lower to the point of being parallel to the
opposite leg.

Use fist percussion over the costovertebral
angles to discriminate flank pain caused by
renal disease from spinal pathology. Apply
fist percussion over the costovertebral angles
and over the spine to localize tenderness.

Perform Range of Motion of the Spine
Ask the patient to flex, extend, rotate, and
bend the spine laterally. Decreased mobility
and back pain along the spine may indicate
muscle spasm, neoplasm, or bony deformity.
Pain with forward flexion usually indicates
a mechanical cau se. Back exten sion pain
increases with spinal stenosis.

Look for compensating effects of hip
motion on the spine. The absence of lumbar
flexion may be totally masked by a normal
range of hip flexion when the patient bends
forward. Test lumbar flexion by placing a mark

FIGURE 24.2 The FABER maneuver (flexion, abduction, externa l rotation at the hip) . (From Cummings
Stanley-Green S, Huggs P: Perspectives in athletic training, St. Louis, 2009, Mosby.)

I

Chapter 24 • Low Back Pain (Acute) I 343

0
,,er the fourth lwnbar vertebra and another

over the sacrum. Lumbar flexion is demon­
strated by an increased distance between these
rwo marks when the patient bends forward.

A modified Schober test can be used to
assess lumbar mobility. With the patient
standing erect and heels together, draw a mark
on the skin 5 cm below an imaginary line be­
rween the buttock dimples overlying the pos­
terior superior iliac spine. A second mark is
made 15 cm above this line. Then have the
patient bend forward touching their toes. An
increase in distance between these lines of
6 cm or more is normal; less than 6 cm indicates
decreased lumbar spine mobility (Fig. 24.3).

Observe for limitation of motion on for­
ward bending caused by hip flexion contrac­
ture. Lumbar lordosis does not flatten with
forward bending and is an organic cause for
back pain. In children, Scheuermann disease,
an exaggeration of the normal posterior con­
vex curvature of the thoracic spine, produces
pain with forward flexion , and spondylolysis
produces pain with hyperextens ion.

Perform Straight Leg Raising
The straight leg raising (SLR) test can assess
sciatic (L5 and S 1) nerve root tension. With the
patient supine, place one hand above the knee,

the other cupping the heel, and slowly raise the
limb. Instruct the patient to say when to stop
because of pain. Observe for pelvic movement
and the degree of leg elevation when the pa­
tient tells you to stop. Ask the patient to tell you
the most distal point of pain sensation, such
as the back, hip, thigh, or knee. While holding
the leg at the limit of elevation, dorsiflexing the
ankle and internally rotating wi ll add tension to
the neural structures and increase the pain if
nerve root tension is present.

Pain below the knee at less than 70 de­
grees of elevation that is aggravate d by
dorsiflexing the ankle or hip rotation is a
sign of LS or S 1 nerve root te nsion, sugges­
tive of a herniated dis k. This test can also
be performed with the patient sitting. In a
positive test res ult, the patient will resist
extension or will compensate with hyperex­
tension of the spine.

Lift each leg in succession to detect con­
tralateral pain in patients with nerve root
compression.

Results of the SLR test in children with a
tumor can be unremarkable.

Check Hip Mobility
With the patient prone and supine, check active
hip flexion , extension, interna l and external

Finger-to-floor distance

Modified Schober test (normal: total >20 cm)

t ·.i: cm

S2 —–r- . – ­

T · ~n·1—:r- . -‘-·• I

/ —l~~-cm ,
S2 – – – – – – –

5cm

Finger-to-floor
~—- distance

B Flexion

FIGURE 24.3 Performing the modified Schober test for spina l flexibility. (From Lawry G, Kreder H, Hawker G,

Jerome D: Fam’s musc uloskeletal examination and joint injection techniques, ed. 2, Philadelphia, 2 011, M osby.)

Chapter 24 • Low B ack Pain (Acute)

rotation , and strength against resistance. Weak­
ness of the gluteus maxi mus is associated with
lumbar or referred pain from LS nerve roots or
gluteal nerve injury. In small children, check
for congenital hip dysplas ia with the child su­
pine and abducting the hips (see C hapte r 22).
The knees s h ould appear of equal height and
should rotate externally by equal degrees. The
presence of a hip c lick, joint instability, uneven
hip-to-knee length with hips and knees flexed ,
and uneven gluteal skinfolds suggests congen i­
tal hip dislocation.

Examine Feet
Perform active range of motion of the ankle,
feet, and toes against resistance. Weakness,
pain, or limitation of dorsiflexion movement
indicates an L4 nerve root injury. Similar
symptoms produced by plantar flexion indi­
cate S 1 involvement, while symptoms pro­
duced by dorsiflexion of the big toe indicate
LS involvement. Deformities of the foot,
such as talipes equinovarus (clubfoot) or
hallux malleus (claw toes) , may aggravate
misalignment of back structures because of
asymmetry.

Evaluate Muscle Strength
Evaluate strength against resistance of the
lower extremity muscle groups. Test the pa­
tienCs ability to stand on the toes and heels
and to squat. A person with SI nerve root in­
volvement may have little motor weakness but
may demonstrate difficulty in toe walking.
Difficulty with heel walking or squatting indi­
cates invo lvement of LS and L4 nerve roots.
Leg extension at the knee against resistance
tests L4 root function. In young children who
are unable to cooperate for measurement of
muscle strength, use measure ments of s imilar
limb girths as an estimate of the bilateral sym­
metry of muscle strength.

Measure Muscle Circumter em·;e
Differences in muscle circumference greater
than 2 cm in two opposite limbs may signify
atrophy secondary to neurologic impairment.

T~~~t. Sensory Function
Neurologic test res ults are evaluated by
comparing the symmetry of responses or

perceptions. Bilateral comparison is the sirn.
plest, most efficient way to detennine the
presence, location, and ex tent of any abnor­
mality. A sensory examination is a general
guide in determining the level of spinal cord
involvement. Test for light touch and pain
sensation in the sensory areas of L3 to SJ
dermatomes (see Fig. 24.4). Dennatornes
overlap a nd vary greatly in individuals; thus

‘ on ly gross chan ges can be detected by
pinprick. Test 5 to l 0 pinpricks in each der­
matomal area if the patient reports numbness
and tingling. Disk lesions rarely produce
bilateral symptoms. It is sometimes difficult
to distinguish numbness from a cutaneous
nerve versus a dennatomal origin. Numbness
from cutaneous nerve lesions does not occur
in a dermatomal pattern. Numbness and tin­
gling are uncommon symptoms in most chil­
dren with back pain. When these symptoms
are present, it suggests a serious problem.

Assess Deep Tendon Reflexes
Normal deep tendon reflexes (DTRs) are
symmetrical. DTRs are increased when an
upper motor neuron lesion is present and de­
creased with a lower m otor neuron lesion. A
positive Babinski sign indicates a disorder of
upper motor neurons affecting the motor area
of the brain or corticosp inal tracts c aused by
spinal tumors or demy e linating disease. DTRs
are decreased if a tumor is pressing on a
peripheral nerve. A symmetric abdominal
reflexes are seen in tumors of the spine.

An absent or a decreased ankle-jerk reflex
suggests an S 1 nerve root lesion. An L3 to L4
disk herniation is the most common cause of
a diminished knee-jerk reflex.

Palpate the Abdomen
The abdomen is palpated to detect possible
visceral causes of back pain. In adu lts older
than 50 years, a ruptured aortic aneurysm can
cause acute, severe, midthoracic back pain. If
an aortic aneurysm is s uspected, immediate
s urgical referral is critical.

Check Rectal Sphincter Tone
In cauda equina syndrome, the compression
of S 1 to S2 nerve roots results in decreased
sphincter tone and decreased sensation in the

Chapter 24 • L ow Back Pa i n (Acute)

AGURE 24.4 Dermatomes of the body, the area of body surface innervated by particular spinal nerves; Cl
has no cutaneous distribution. A , anterior v iew. B , posterior view. (From A: Rudy, EB: Advanced neurological
andneurosurgical nursing. 1984, M osby, St Louis. 8 : Thibodeau, GA, Patton , KT: Anatomy and physiology.
ed 5, 2003, Mosby, St Louis)

perianal area. This syndrome 1s a surgical
emergency.

LABORATORY AND DIAGNOSTIC
STUDIES

According to national practice guidelines, no
diagnostic tests are w arranted within the first
4 weeks for onset of A LBP without neuro­
logical signs or sympto m s.

Spinal Radiographs
Aflat lumbosacral spi n e:! •::ldiograph is obtained
when there is a history ~ f trauma or in people
older than 50 years who hav e ALBP with s igns
of neurologic deficit a his tory of straining or
lifting. Anterior and p osterior view radiographs
are useful in ruling out :fracture, tumor, osteo­
phytes (bone spurs), or vertebral infection.

Oblique and flexion