Case Study: Diagnosis and Treatment of a Patient with Upper Back Pain

This case study presents the diagnosis and treatment of a patient, Mr. Henry, experiencing upper back pain. The assessment includes subjective reports of pain intensity, accompanied by a headache, and objective findings from physical examinations focusing on the lumbar and cervical regions. The objective section outlines rotational motion degrees and test results, including the vertebral artery test and an abnormal Piriformis test. Radiology results provide information about the cervical spine, pelvic area, and lumbar spines. A body posture analysis reveals poor posture. The assessment indicates muscle spasm, lumbar region dysfunction, and cervical spondylitis. The treatment plan includes electromyography, electrical transcutaneous nerve stimulation, specific exercises, cortisone injections (if needed), and the continuation of analgesics and anti-inflammatory medications. The case study also emphasizes the importance of avoiding excessive physical work or stress and anticipates medical improvement within six months. References to supporting research are also included.

Running head: DIAGNOSIS AND TREATMENT OF A PATIENT WITH BACK PAIN
Diagnosis and treatment of a patient with back pain
Name of the Student
Name of the University
Author Note

1DIAGNOSIS AND TREATMENT OF A PATIENT WITH BACK PAIN
SUBJECTIVE:
Mr. Henry reports that he is suffering from upper back pain and which is the primary
purpose of his appointment. Pain is a sensational signal that travels through nerve fibres into
the brain and accordingly, the body responses (Yam et al.,2018). The back pain also
accompanies with a headache. His condition of pain was 5/10 which is very uncomfortable
sometimes. The pain is severe and his daily actions are also affected by the signs. The pain
arises from the lower extremes and spreads upwards; it increases more when standing for a
more extended period or while sitting in a fixed period for hours. Heat pads relieve the pain
to some extent. No history of previous medication was reported along with any laceration.
OBJECTIVE:
LUMBAR REGION-
The degrees of rotational motions found in this area are-Flexion and Extension- 10
degrees and 16degrees, and for lateral bending the value is11degrees.
The flexion and the extension are abnormal compared to normal. The average values are 2-11
degrees for flexion and extension; for lateral bending, it is 2-7degrees.
CERVICAL REGION-
The degree of rotational motion found for flexion is 55 degrees for both right and left
lateral sides. The extension degree found is 60.
The values are average which reveals that the motion in the cervical region is under average.
TESTS-

2DIAGNOSIS AND TREATMENT OF A PATIENT WITH BACK PAIN
The vertebral artery test was found to be healthy. It is a kind of test used to identify
the position of the neck, which also reveals information about any tearing that occurred in the
neck.
The result of the Piriformis test was found abnormal. This test is used to screen the
piriformis muscle along with the tightness of the muscles. It also screens defects about the
sciatic nerves (Hopayian & Danielyan 2018).
RADIOLOGY RESULT-
The analysis of the body’s soft tissues or damage in the disc is done by this method.
The image discloses information about the cervical spine, pelvic area as well as lumbar
spines.
BODY POSTURE ANALYSIS-
Mr. Henry was found to have poor body posture by the digital analysis of the body.
The lateral sight of the body was found to be abnormal due to the defective position of the
head over the chest or thoracic cavity which may have given rise to musculoskeletal
complaints. The pelvic region is rotated and the right hip portion is found to be switched.
ASSESSMENT-
The patient is suffering from muscle spasm, dysfunction in the lumbar region as well
as cervical spondylitis.
PLAN-
Electromyography or pulse stimulation can be given in the low back and thoracic region for
15minutes.

3DIAGNOSIS AND TREATMENT OF A PATIENT WITH BACK PAIN
Electrical Transcutaneous nerve stimulation can be given for 10 minutes.
Exercises must be done to stretch the shoulders, low back as well as hip.
Cortisone injections can be given if pain increases.
Analgesics and anti-inflammatory medicines need to be continued for a few days (Sailaja,
2015).
Moist heat can be applied in the areas of the shoulder and neck.
Any excessive physical work or stress should be avoided during the period of medication.
This can increase the pain and may lead to the severity of the condition. (Searle, Spink &
Chuter 2015).
The patient is expected to be healthy with medical improvement within six months.

4DIAGNOSIS AND TREATMENT OF A PATIENT WITH BACK PAIN
References
Hopayian, K., & Danielyan, A. (2018). Four symptoms define the piriformis syndrome: an
updated systematic review of its clinical features. European Journal of Orthopaedic
Surgery & Traumatology, 28(2), 155-164.
Sailaja, A. K. (2015). Treatment for low back pain attributed to underlying presumptive
etiology. Am J Drug Deliv Therap, 2(1), 001-008.
Searle, A., Spink, M., Ho, A., & Chuter, V. (2015). Exercise interventions for the treatment
of chronic low back pain: a systematic review and meta-analysis of randomised
controlled trials. Clinical rehabilitation, 29(12), 1155-1167.
Yam, M. F., Loh, Y. C., Tan, C. S., Khadijah Adam, S., Abdul Manan, N., & Basir, R.
(2018). General pathways of pain sensation and the major neurotransmitters involved
in pain regulation. International journal of molecular sciences, 19(8), 2164.