Need help? We are here

O.

Vital signs:  B/P 135/72; Pulse 83; RR 18; O2 Sat 98%; Temp. 98.3; Wt. 205 lbs.; Ht. 72”

General:  Patient sitting on edge of the exam table, appears restless and anxious.  He is alert and oriented x3 and responds appropriately to all questions.

Skin:  Warm, dry, and intact.  No evidence of rashes, lesions, wounds, or cysts. Adequate turgor.

Respiratory:  Breath sounds clear and equal upon auscultation in all 4 lobes anteriorly and posteriorly.  No adventitious sounds heard.  Symmetrical chest wall expansion noted.  No difficulty in breathing patterns noted.

CV:  Heart RRR, no audible murmurs or gallops.  No peripheral edema noted.  Tibial and dorsalis pedal pulses present, 2+ bilaterally Capillary refill less than 3 seconds in fingers and toes bilaterally, with no cyanosis noted.

Abdomen:  Soft and nontender.  No distention; no palpable masses.  Bowel sounds normoactive in all 4 quadrants.  No evidence of guarding. No flank tenderness noted bilaterally.

Rectal:  No prostate tenderness or enlargement noted upon palpation.

Back:  Spine straight with no obvious curvature.  Full ROM of the spine, but tenderness reported upon palpation of the sacroiliac region.    

Musculoskeletal:  full weight-bearing.  No evidence of gait disturbances.  Full ROM noted in all 4 extremities. Leg measurements are equal.  Positive FABER test upon placing the left leg on right knee, pain reported in the sacroiliac region. Straight leg raises performed bilaterally, with complaints of pain verbalized upon 45 degrees of elevation.  Pain in the sacroiliac region also voiced upon left ankle dorsiflexion (Dains, Baumann, & Scheibel, 2019, Chapter 24).  

Neurological:  Alert and oriented x 3; appropriate mood and affect in the present circumstance of constant pain.  No foot drop noted when examined bilaterally (Dains et al., 2019). Reflexes are 2+ and equal bilaterally, including deep tendon (Dains et al., 2019).  Strength is 5/5 in all extremities except for left leg, which is assessed at 4/5 (Sullivan, 2019, Chapter 2).  No evidence of limping with ambulation.

Diagnostic Results:

CBC:  WBC 14, 500; HgB 12.3; Hct 46%.  While this patient’s WBC is only slightly elevated, it is important to consider the presence of an infection in the back or spinous processes.  While he has not reported any fever or chills, clinicians can never be too certain that there is not a hidden bacterium that would be the causative agent for the reported symptoms (Dains et al., 2019).  Additionally, as the thought of a malignant condition is always in the minds of patients and clinicians, alike, it is essential to assess the H & H of the individual (Dains et al., 2019).  While anemia is commonly present amongst cancer diagnoses, ranging anywhere from 30% to 90% of diagnosed patients, the extent of such a condition will vary according to the type of tumor (Krasteva, Harari, & Kalsi, 2019).

UA:  negative for blood, nitrites, or bacteria.  As the advanced practice nurse, it is equally important to ensure that there is no specific visceral involvement, such as what can occur with the kidneys when there is infection present (Dains et al., 2019).  The U/A results would be helpful information to rule out a condition known as pyelonephritis (Dains et al., 2019).

ESR:  25 mm/hr A hematologic test, known as an erythrocyte sedimentation rate, is very useful when trying to conclude if infection, inflammation, trauma, or even malignant disease is present (Patil, Muduthan, & Kunder, 2019).  While the ESR can be initially elevated in the acute stages of an illness, it is a significant enough diagnostic test to perform when trying to rule out infection as the underlying cause of the condition (Patil et al., 2019).

PSA:  9.2.  The elevated PSA level in this gentleman does warrant enough suspicion for the advanced practice nurse, as there is always a potential for prostate cancer with bony metastasis in the spinal region (Bakhsh et al., n.d.).  The bony lesions that are found in metastatic prostate cancer are typically osteoblastic in nature (Bakhsh et al., n.d.).

MRI:  awaiting the radiologist report.  The condition of the soft tissue in the spinal region is best visualized with magnetic resonance imaging (Dains et al., 2019).  There are medical conditions that need to be ruled out as a source of the back pain, such as disc herniations, tumors, and various diagnoses that originate from the spinal cord (Dains et al., 2019).

A.

1.) Sciatica:  While it is vital that other medical conditions that originate from the spine are reviewed, sciatica is a presumptive diagnosis for this male patient that is experiencing low back pain.  The long-standing nursing career of this male patient often involves a great deal of twisting, bending, and lifting that has become repetitive (Dains et al., 2019).  The bowel and bladder functions are not usually compromised, but the patient will experience a significant amount of pain, burning, and even numb sensations in the buttock and leg of the affected side (Dains et al., 2019).  The straight leg raises test (SLR) will usually reveal positive results, which was the case of this male patient (Dains et al., 2019).

2.) Primary or metastatic tumor:  The advanced practice nurse must rule out the presence of a tumor type, first and foremost, before proceeding on to other differential diagnoses.  While this patient may not have all the “classic” indicators of malignancy, it is vital that clinicians understand that no one patient will present with a malignant condition in the same exact fashion.  The elevated PSA in this young 42-year-old male is enough indication to ensure that a malignant condition is not the underlying cause for his symptomology.  The weight loss that the patient has reported is a symptom that does require further exploration.

3.) Disc Herniation:  Although numbness and tingling are not as common with a disc herniation, patients with such a condition will usually complain of pain that radiates throughout the leg of the affected side (Dains et al., 2019).  The patient with a herniated disc will quite frequently have positive straight leg tests, and an MRI is undoubtedly warranted if the patient has experienced back pain for at least one month (Dains et al., 2019).

4.) Infection:  A condition known as osteomyelitis can often occur in the spine, especially if the patient has experienced recent infection in a neighboring anatomical region or if they have undergone a type of invasive procedure where various instrumentation was utilized (Dains et al., 2019).  Sadly enough, infection ranks high in the medical community as one of the most overlooked conditions by well-intended clinicians (Mohamed, Finucane, & Selfe, 2019).  The cause for many of these errors that pertain to spinal infections is because of the extended period between the time of initial onset to the time of full development of the condition (Mohamed et al., 2019).  The consideration of infection is very prudent with this male patient, as his slight WBC elevation and ESR level do require further exploration.

5.) Spinal Stenosis:  While this condition is typically diagnosed in those patients over 50 years of age, the advanced practice nurse must take into consideration the length of time that this male patient has endured long hours on his feet in his nursing career.  Spinal stenosis of the lumbar region is a common location and is usually associated with degenerative changes of the three-joint complex (Abbas, Peled, Hershkovitz, & Hamoud, 2019).  The presence of neurogenic claudication is an anticipated clinical symptom, with pain levels increasing upon long periods of standing (Abbas et al., 2019).  The pain will normally radiate to one or both buttocks, legs, and feet (Abbas et al., 2019).