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Review Of Case Study For Back Pain Assignment

Review Of Case Study For Back Pain Assignment

Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study you were assigned.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Note: Before you submit your initial post, replace the subject line (“Discussion – Week 8”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned. Review Of Case Study For Back Pain Assignment

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By Day 3 of Week 8
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each Review Of Case Study For Back Pain Assignment.

A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?

Patient Information:

Mr. R, 42-year-old, male.

S.

CC Pain in his lower back.

HPI: Mr. R is a 42-year-old male who reports to the hospital with a chief complaint of pain in his lower back. The onset of the pain was three months ago. The pain sometimes radiates to his left leg. There are no associated symptoms or timing of escalation or de-escalation of the pain. Review Of Case Study For Back Pain Assignment

Current Medications: No current medications

Allergies: No known allergies

PMHx: No medical history

Soc Hx: No defined social history.

Fam Hx: No family history

ROS:

  • GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.
  • HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.
  • SKIN:  Denies rash or itching.
  • CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
  • RESPIRATORY:  Denies shortness of breath, cough or sputum.
  • GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
  • GENITOURINARY:  Denies burning on urination.
  • NEUROLOGICAL: Numbness on the lower back and occasionally on the left leg. Denies headache, dizziness, syncope, paralysis, and ataxia.
  • MUSCULOSKELETAL:  Pain in the lower back and on the left leg.
  • HEMATOLOGIC:  Denies anemia, bleeding or bruising.
  • LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.
  • ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
  • ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.

O.

Physical exam: Results show pain in lower back, buttock and down the left leg. Weakness in the patient’s lower back and in the left leg.

A physical exam on the impact on pain during movement and rest is important. The feeling on the toes and feet should be assessed. A full assessment of the urinary tract region is important (Almeida, & Kraychete, 2017).

Diagnostic results: The CBC levels are moderate. Sedimentation rate, CRP and uric acid levels are within normal range. The spinal X-ray shows unusual curves between the vertebrae of the joints in the lower spine (Khalimova, 2021).

The nerve roots concerned are the five nerve roots that compose the sciatic nerve. Three of them from the lower lumbar and two of them from the upper sacral spine. Electromyography is the best way to test these nerve roots. The test reveals problems of nerve dysfunction or transmission if any (Almeida, & Kraychete, 2017)Review Of Case Study For Back Pain Assignment.

Additional symptoms that would help finalize a diagnosis include the change in bowel and bladder control. The impact of the pain on limbs movement is important (de Campos, 2017).

A.

Differential Diagnoses

  • Sciatica: It is characterized by pain travelling in sciatic nerve which is usually in the lower back and extends though the hips to the legs. The symptoms of the patient are aligned with these symptoms (de Campos, 2017).
  • Piriformis syndrome: It causes pain in the lower back and upper leg due to muscle pressing on the sciatic nerve. The condition disappears in a few days (Khalimova, 2021).
  • Sacroiliac joint dysfunction: It symptoms include irregular sleep patterns, leg instability, and pain in the lower back and legs due to improper joints movement (de Campos, 2017).
  • Myelopathy: It a severe spinal cord injury that is caused by excess compression and can be symbolized by pain in the lower back (Khalimova, 2021).
  • Spinal stenosis: It is caused by restructuring of nerves in the spine due to arthritis. Its symptoms include pain in the back, legs, and arms (Khalimova, 2021)Review Of Case Study For Back Pain Assignment.

References

Almeida, D. C., & Kraychete, D. C. (2017). Low back pain – a diagnostic approach. Revista Dor, 18(2). http://www.gnresearch.org/doi/10.5935/1806-0013.20170034

de Campos, T. F. (2017). Low back pain and sciatica in over 16s: assessment and management NICE Guideline [NG59]. Journal of Physiotherapy, 63(2), 120. https://www.sciencedirect.com/science/article/pii/S1836955317300255?via%3Dihub

Khalimova, D. J. (2021). RESULTS RESEARCH OF LOWER BACK PAIN USING THE ORIGINAL LOW BACK PAIN CHARACTERIZATION QUESTIONNAIRE. UZBEK MEDICAL JOURNAL, Special issue(3), 30–34. https://tadqiqot.uz/index.php/medical/article/view/2905/27Episodic/Focused SOAP Note Template

 Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example: Review Of Case Study For Back Pain Assignment

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. Review Of Case Study For Back Pain Assignment

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)Review Of Case Study For Back Pain Assignment

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A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

P.  

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. Review Of Case Study For Back Pain Assignment