Spondylolisthesis, Facet Joint Cyst, and Herniated Nucleus Pulposus

Female Genitourinary, & Musculoskeletal
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1 What other subjective data would you obtain?
All of the subjective data must contain the patient’s complete demographics and the date of the interview. In this case, the interviewer elicited the onset of the illness, precipitating factors, relieving factors, and severity (Bickley & Szilagyi, 2012).
The interviewer missed the opportunity to elaborate on the quality of pain and the presence or absence of radiation. This is important because low back pain can be secondary to many causes, such as mechanical causes or referred pain from the internal organs such as the kidneys. For instance, mechanical low back pain is secondary to problems with the spinal column, including the intervertebral disks, bones, muscles, and joints connected to it. There are also various forms of mechanical low back pain. An example of this is a malignancy, which may present as a local tenderness and pain (Will et al., 2018).
Moreover, the interviewer failed to elicit associated symptoms that will hint at the type of the disease. An example of this is the presence of fever, which is indicative of an active inflammatory response. Another example is the presence of unintentional weight loss, which gives a clue that the case may be secondary to malignancy (Will et al., 2018).
The drug history should be complete, including the dose, frequency, and duration of use (Bickley & Szilagyi, 2012). Moreover, the generic name should be used, and the brand name should be enclosed in parentheses in documenting the case. Aside from this, the interviewer must clarify if the medications are actively being taken as of the moment or not.
The family history should also contain the pertinent negatives so that when other health providers read the chart, they are confident that the interviewer could ask all the possible heredofamilial diseases (Bickley & Szilagyi, 2012). The social and environmental histories should also be asked since this is a possible orthopedic case, and cases like these are typically precipitated by their posture related to their everyday activities (Tousignant-Laflamme et al., 2017).
Lastly, the subjective data must contain the review of systems to ensure that the clinician will not miss other important details that the patients thought were not significant in diagnosing their disease (Bickley & Szilagyi, 2012).
2 What other objective findings would you look for?
First, the clinician forgot to take the patient’s height and weight, the data needed to compute the body-mass index (BMI). Frilander et al. (2015) explained the connection between obesity and mechanical low back pain development. The study revealed a higher prevalence of low back pain in obese patients than those with normal BMI. Moreover, the duration from which the person has been obese is also associated with the presence or absence of radiation to the lower extremities. On top of these, the general survey should also take note of the patient’s body type (i.e., ectomorph, mesomorph, or endomorph) and general posture upon arriving at the clinic. The latter will show position biases, possibly the position of relief (i.e., flexion or extension bias) (Cioffredi, n.d.).
Manual muscle testing of the lower back and lower extremity muscles should be done to have a baseline record of the strength. This will help identify progressive muscle weakness, a red flag in a patient with mechanical low back pain (Allegri et al., 2016; Will et al., 2018).
The kidneys also typically refer to pain in the low back area. Therefore, Murphy’s punch sign should be tested on the bilateral costovertebral angle. This test is typically positive in patients with perinephric abscess, pyelonephritis, and other related kidney diseases (Bailey et al., 2013).
3 What diagnostic exams do you want to order?
Plain Radiography of the Lumbar Spine
This cannot directly visualize an impingement or a herniated disc. Instead, it can only detect the factors that might lead to these, such as an infection, osteophyte formation or osteoarthritis of the spine, spinal misalignments, and tumors. As a result, the said factors might cause impingement of the nerve roots that exit the lumbar spine, which results in the sharpshooting localized pain on this area (Will et al., 2018; Mayo Clinic, 2019).
Magnetic Resonance Imaging of the Lumbar Area
This visualizes soft tissues, such as the nerves or nerve roots impinged at a specific area (Will et al., 2018). This is also important in visualizing spinal tumors that may obstruct the lumbar area or herniation of the nucleus pulposus (El Sayed & Callahan, 2021). This works by employing radio waves that create a strong magnetic field, which constructs an image of the internal structures, specifically the soft tissues. This diagnostic test rules in or rules out the presence of a herniated disc or nerve impingements (Mayo Clinic, 2019).
Aside from this, MRI can also be used to visualize any spontaneous reduction of the affected segments in spondylolisthesis with instability. This will be helpful in the referral to allied health professionals, such as physical therapists, in understanding whether the segmental instability is secondary to paraspinal muscle spasm (Chung et al., 2012).
4 Name three differential diagnoses based on this patient presenting symptoms?
The three differentials are herniated nucleus pulposus, facet joint cyst, and spondylolisthesis.
5 Give ration...