Mr. X, a 42-year-old male presents to your primary care practice today complaining of low back pain.
History â€“ Mr. X states that he has had chronic low back pain since he had a skiing accident about 10 years ago. Three days ago, he felt a pulling sensation in his lower back after moving some boxes. The pain intensity increased over the subsequent 24 hours and is now steady, aching in nature, at 3-4 out of 10. Mr. X also has Type2 diabetes, which is well controlled on metformin with a HGA1c of 5.6. He has a history of DVT 4 months ago for which he takes Coumadin, INR is WNL. He is followed by a specialist for this problem. He recently started taking two OTC products; kava kava for what he describes as â€œanxietyâ€ and CoEnzyme Q10 on the advice of a friend.
Social – Mr. X is a smoker, 1 pack per week for 15 years. No alcohol or drug use. He is employed as an accountant and has medical insurance. He is divorced.
PE/ROS – Complains of low back stiffness and pain on movement with occasional spasms related to moving in certain directions. You note he has mild difficulty getting onto the exam table but gait is normal. He denies weakness/numbness/tingling of legs, no radiation, no change in bowel or bladder habits. BMI 27. All range of motion of the back is decreased by 25%. Straight leg lift is negative bilaterally, DTR intact. All other systems WNL.
Metformin 1000mg ER one tab daily – Type II Diabetes controlled
Coumadin 5 mg. daily – Hx of DVT – Controlled
Kava Kava 50 mg. tid â€“ Self-medication for anxiety
CoQ10 – 200 mg. daily. â€“ Self-medication for unknown reason
Provide a diagnosis for the patient and your rationale for the diagnosis
Provide a treatment plan specifically for this patient, pharmacologic and non-pharmacologic.
Comment on the use of OTC products in relation to Mr. Xâ€™s current chronic and acute disease diagnoses and medications. Include drug-drug interactions and side effect profiles.
Provide an education plan for Mr. X