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During the initial assessment of the patient, several vital components should be included to gather comprehensive information. The evaluation will involve observing the patient’s gait, posture, and signs of discomfort. Additionally, evaluating the range of motion and palpation of the back is crucial to assess the spine, paraspinal muscles, and sacroiliac joints for tenderness or masses. Given the patient’s complaint of pain radiating to the thigh, an initial assessment will include the straight leg raise test. This test aids in evaluating lumbosacral nerve involvement and identifying sciatic nerve compromise, as it is a provocation test known to elicit pain in patients with compromised sciatic nerve functioning (Camino & Piuzzi, 2019). Muscle strength testing and assessment of lymph nodes are also essential to identify potential issues related to nerve function and lymphadenopathy associated with tumors.

To gather more information about the patient’s symptoms, specific questions will focus on the onset and progression of back pain, pain characteristics (including radiation), medication history for back pain management, previous treatments, imaging history, and overall medical and psychological history.

Assessing the patient’s psychological status is crucial, particularly in cases where psychological distress may manifest as back pain with inappropriate physical signs, known as Waddell’s signs (Dâ€™Souza et al., 2024). Patients presenting with three or more of these signs may indicate a psychological component to the back pain, requiring psychological management in addition to conventional care.

Conditions warranting an X-ray for acute low back pain (ALBP) include the presence of red flags such as significant trauma, unexplained weight loss, history of cancer, fever, or signs of neurological deficit. Suspicion of fracture, suspected spinal infection, and inflammatory disorders like ankylosing spondylitis also warrant an X-ray (AlAteeq et al., 2020).

The plan of care for this patient involves pain management, including medication and nonpharmacological interventions. Prescribed medications include cyclobenzaprine 15 mg PO daily for 14 days to address skeletal muscle spasms and ibuprofen 600 mg PO every 8 hours for five days, with careful monitoring for gastrointestinal risks. Tylenol 1000 mg PO every 8 hours for one week may also be recommended. Non-pharmacological care includes physical therapy to improve muscle strength, flexibility, and core stability. Patient education emphasizes lifestyle and activity modification, proper body mechanics, prolonged sitting and standing avoidance, and using heat/ice therapy for pain relief. Strict adherence to the medication regimen and follow-up plan is crucial for optimal outcomes.

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