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Discussion Assignment:

Respond to the following Case study:

Explain how you might apply knowledge gained from the Response case studies to your own practice in clinical settings.

· Share additional interview and communication techniques that could be effective with your colleague’s selected patient.

·

· Suggest additional health-related risks that might be considered.

·

· Validate an idea with your own experience and additional research.

·

· Explain your reasoning using at least TWO different references from current evidence-based literature in APA Format.

Age: _42__                            Gender: ___Male___

SUBJECTIVE DATA:

Chief Complaint (CC): Back Pain

History of Present Illness (HPI):  A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg.

Medications:

Multivitamins 1 tab daily, Motrin 800mg q4-6hr

Allergies: No Known Allergies

Past Medical History (PMH): none

Past Surgical History (PSH): none

Sexual/Reproductive History: Heterosexual single male for 10 years and no sex for 1 year.

Personal/Social History: Smoking in the past since19 year of age: Recently quit 2 months ago

Immunization History: Up to date. Recent influenza given 12/30/1985 at this clinic

Significant Family History:  No kids. Never married. Paternal Grandma HTN, Diabetes age 81, Mother HTN Age 69, Father Diabetes, HTN Age 68

Lifestyle: LB work as a registered nurse at Triangle springs over 10years.  LB lives in a house he bought in Cary, NC over 4 years ago. LB is a Jehovah Witness but doesn’t practice. LB feels safe at home and denies any signs of depression. LB family are very supportive and they go for family date once every week. LB had a weight loss over a year of 5bs.

Review of Systems:

General:

LB is a pleasant, 42-year-old Caucasian who presents with back pain. He is the primary source of the history. LB offers information freely and without contradiction. LB speech is clear and coherent. He maintains eye contact throughout the interview

HEENT:

LB does not wear any corrective eye and have not visited an optometrist in over 3 years. Dental was 1 year ago. Denies any other complications.

Neck

Thyroid smooth, no goiter or lymphadenopathy

Breasts:

No history of lesions, masses and/or rashes

Respiratory:

Denies cough, dyspnea, wheezing, or shortness of breath.

 

Cardiovascular/Peripheral Vascular:

Reports no tachycardia, edema, palpation or easy bruising.

Gastrointestinal:

Denies food intolerance. No reports of pain, vomiting, constipation, diarrhea, nausea and/or indigestion.

Genitourinary:

No reports of flank pain, dysuria, nocturia, polyuria, and/or hematuria

Musculoskeletal:

Lower back pain over one month ago with radiation to the leg pain a 9/10 and increases higher with standing or sitting long periods of time. Motrin eases pain 1-0/10. Denies numbness. Denies weakness. Pain 0/10 at rest.

Psychiatric:

Denies any depression, suicidal thoughts or ideation. No anxiety

Neurological:

No loss of coordination or sensation, dizziness, lightheadedness. No sense of disequilibrium or seizures.

Skin:

No rashes, no moles

Hematologic:

Reports no blood disorders or complications

Endocrine:

No endocrinology symptoms nor hormone therapies

Allergic/Immunologic:

No allergies

OBJECTIVE DATA

Physical Exam:

Vital signs:

Temperature 98.2, BP 122/77, Resp 14, Spo2 100, HR 64, Ht 69 inches Wt 202lbs. BMI 21.6

HEENT:

PERRLA, Head, ears, eyes and mouth are symmetry. Snellen chart showed 20/20 in both eyes. Equal hair distribution of hair on eyebrows, lashes, head. Gag reflex intact. Whisper heard bilateral. Oral mucosa is moist and has no lesion or pain. Nasal mucosa pink and moist.

Neck

Thyroid smooth, no goiter or lymphadenopathy.

Chest/Lungs:

Chest is symmetry.  Auscultation clear lower and upper lobe bilaterally. Resonant percuss throughout.

Heart/Peripheral Vascular:

S1, S2 without murmurs, rubs and or gallops. Heart regular. PMI is at midclavicular line, 5th intercoastal space with no thrills, lifts, and heaves. Bilateral peripheral pulses equal. Capillary refill less than 3 seconds. No peripheral edema. Bilateral carotids equal without bruit

.

Abdomen:

Bowel sounds normoactive in all four quadrants. No tenderness or guarding during palpation. No organomegaly. Abdomen symmetric, no scars and/or lesions. Tympanic throughout percussion.

Musculoskeletal:

Full ROM in bilateral upper and lower extriemities, No swelling, deformity, or swelling.

Neurological:

Equal bilateral in upper and lower extremities and DTRs 2.CN II -XII grossly intact.

Skin:

No rashes, warm to touch, no wounds.

 Labs:

X ray, CT scan, and/or MRI to look at the bones in lumbar and find the issue

CBC and Urinalysis to check for infection/UTI

ASSESSMENT:

Watch LB walk to check gait. Also lay flat, bend and others that can help me identify LB limitation and things he can do

Diagnosis

1) Lumbar Herniated Disk. The lumbar spine contents 5 bony segments in the lower back area, which is where lumbar disease occurs. In herniation and or ruptures the disk continues to break down, or with continued stress on the spine, the inner nucleus pulposus may rupture out from the annulus. This is a ruptured, or herniated disk. The fragments of disc material could then press on the nerve roots located right behind the disk space. This can cause pain as to the legs, weakness, numbness, or changes in sensation (Raj M. Amin, 2017). This also causes leg pain which LB has.

2) Sciatica are back pain caused by a problem with the sciatic nerve. This is a large nerve that runs from the lower back down the back of each leg. LB has pain that goes down to his legs. Sciatica happens when something injures or puts pressure on the sciatic nerve, it can cause pain in the lower back that spreads to the leg, hip, and buttocks (Davis & Vasudevan, 2015).

3) Lumbar spinal stenosis happens when the narrowing of the spinal canal, compressing the nerves traveling through the lower back into the legs. LB is having his issues While it may affect younger patients, due to developmental causes, which according to the assessment LB has not or it has gone undiscovered, it is more often a degenerative condition that affects people who are typically age 60 and older. LB does smoking which could affect his bones (Carlos Bagley, 2019).

4) Lower back strain is acute pain that is caused by damage to the muscles and ligaments of the back. It is also referred to as a pulled muscle. … Lumbar muscle strain occurs when a back muscle is over-stretched or torn, which damages the muscle fibers. When one of the ligaments in the back tears, it is referred to as a sprain. LB could have been lifting or pulling heavy object or inappropriate working position. As a nurse taking care of patient and not having the back at your level this could happen (Massimo Allegri, 2016).

5) Idiopathic back pain is back pain that physicians cannot explain because there is not obvious structural cause of the pain like a herniated disc, degenerative disc disease, or stenosis. Idiopathic back pain is the “diagnosis” given by doctors to patients that have chronic which is over 6 months back pain and they have been unable to figure out why (Massimo Allegri, 2016). LB has had back pain for a month but do not know the cause at this time.

Depending on diagnosis LB may need a topical pain cream, physical therapy, surgery, a back brace. LB will need education on proper body mechanics.