Medical Assessment and Treatment Plan for 51-Year-Old Male with Low Back Pain
Diagnosis
The diagnosis is acute nonspecific mechanical low back pain (lumbar sprain). The normal urinalysis rules out urinary tract infection, and the mildly elevated WBC of 10.30 (within normal range for many laboratories) without other systemic signs does not suggest infection or serious pathology 1, 2.
Clinical Reasoning
- The patient presents with low back pain without red flags (no progressive neurologic deficits, no history of cancer, no severe trauma, no fever suggesting infection) 3, 1
- Normal UA excludes UTI as the pain source 1
- WBC of 10.30 is borderline and nonspecific; without fever, weight loss, or other systemic symptoms, this does not warrant concern for serious pathology 3
- No imaging is indicated as routine radiography or advanced imaging is not recommended for nonspecific low back pain without red flags 3, 1
Treatment Plan
Pharmacologic Management (Within 300 Peso Budget)
First-line medication: Ibuprofen 400mg, take 1 tablet three times daily after meals for 7 days. Dispense: 21 tablets. 1, 4, 2
- NSAIDs are the initial medication of choice for acute low back pain with moderate evidence of benefit 1, 4, 2
- Short-term use (7 days) minimizes gastrointestinal and cardiovascular risks 1
- Alternative if NSAIDs contraindicated: Paracetamol 500mg, 1-2 tablets every 6 hours as needed for pain (though evidence is weaker) 4
Non-Pharmacologic Management
- Advise patient to remain active and avoid bed rest, as activity is more effective than bed rest for acute low back pain 1, 2
- Apply heat to affected area for symptomatic relief 4
- Continue normal daily activities as tolerated 1, 2
- Expected improvement within first month; most acute low back pain resolves substantially within 4 weeks 1, 2
Follow-Up Instructions
- Return for reassessment if symptoms persist beyond 1 month or worsen 1, 5
- Seek immediate care if new neurologic symptoms develop (leg weakness, numbness, bowel/bladder dysfunction) 3, 1
Medical Certificate
This certifies that the patient has been seen and examined today with the diagnosis of: Acute Mechanical Low Back Pain (Lumbar Sprain) and recommendation of: Analgesic medication, remain active, avoid bed rest, and symptomatic treatment for 7 days. This medical certificate is issued upon the request of the patient for return to work with light duty modifications (avoid heavy lifting) for 1 week.