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Case Study For Patient Complaining Of Back Pain

Case Study For Patient Complaining Of Back Pain Assignment

Reason for Encounter: back pain

HPI (History of Present illness): Gloria Jenkins is a 65-year-old female who presented to the clinic with the chief complaint of back pain that started two days ago while she was working. The pain is located on her lower back and is described as being sharp in character, felt deep inside her back not on the skin, and is graded as 7/10 on pain scale. The pain is present at all times (continuous), and is unaffected by bending forward or sitting. The pain makes it hard for her to sleep and is worsened when she is working, on moving, rolling over in bed, and walking and standing for a long time. She is currently unable to lift anything. The pain has no known relieving factors and the patient has not tried any treatments for the pain. The pain radiates to the right leg, causing pain in the leg. The pain has since onset not gotten any better and the patient reports that she has never had such pain before. She denies any recent trauma or fall or anything like it. There is no associated weakness or numbness, or tingling sensation on her legs. However, she reports difficulty moving due to the pain. She denies any history of spinal disease or popping sensation heard before the onset of the pain. Case Study For Patient Complaining Of Back Pain Assignment

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Current Medications: She reports that she takes Calcium and vitamin D twice a day for her bones.

Allergies: She denies known/unknown food, drug, or environmental allergies

Pertinent PMHx: The patient reports that she has thin bones, asthma, and high blood pressure for which she is taking medication. The patient reports that she had a complete hysterectomy when she was 42 y/o for bad fibroids. The patient denies any recent hospitalization or hospitalization for symptoms like the ones she has right now.

Social Hx: She reports that she works in restaurant and that her daily work involves a lot of hard or physical labor such as lifting and moving to rearrange tables at the restaurant. I would have asked about whom she lives with, her diet, habits (consumption of alcohol or other drugs), any physical activity, and sexual activity.

Fam Hx: She states that her mother died from cancer when she was 83y/o, and her father died at 72 y/o from a bad heart. She reports that both her son and daughter are alive and well, and that she is unaware of her grandparents’ health. Case Study For Patient Complaining Of Back Pain Assignment

History questions asked:

  • How can I help you today?
  • Do you have any other symptoms or concerns we should discuss?
  • Do you have pain anywhere? If so, where?
  • Where more precisely is the pain in your back?
  • How long does your back pain last?
  • When did the pain in your back start?
  • What are the events surrounding the start of your back pain?
  • Does anything make the pain your back better or worse?
  • Do you have pain/discomfort when you are at rest?
  • Does the pain get better when you bend forward or sit?
  • Does walking or standing for a long time bring on the pain?
  • Do you have pain when lifting?
  • Does the pain in your back radiate someplace else? Where?
  • Is the pain in your back superficial (on the surface) or deep inside?
  • What does the pain in your back feel like?
  • How severe (1-10) is the pain in your back?
  • Have you had the pain in your back before?
  • Any change in your back pain since it begun?
  • What treatments have you has for the pain in your back?
  • Have you had any trauma to your back?
  • Have you recently lifted something heavy or used your back in unusual ways or postures?
  • Does the pain in your back come and go?
  • How often does this back pain occur?
  • Do you have new weakness in any arm, leg, or your face?
  • Do you have any tingling and/or numbness anywhere?
  • Are you taking any prescription medications?
  • Do you have any previous medical, surgical, or dental procedures?
  • Are you taking any over-the-counter or herbal medications?
  • Do you have any allergies? Case Study For Patient Complaining Of Back Pain Assignment

Review of Systems

General: Gloria Jenkins is a 65-year-old female who presented to the clinic with back pain. She denies any problems with fatigue, difficulty sleeping, unintentional weight loss/gain, fevers, or night sweats. However, she notes that the pain negatively impacts her sleep as she experiences worsening pain on rolling in bed.

Skin: She denies any problems with an itchy scalp, skin changes, moles, thinning hair, or brittle nails.

HEENT: She denies having intractable headache, blurred vision, and difficulty with night vision, problem hearing, ear pain, sinus problems, chronic sore throats, or difficulty swallowing.

Breast: She denies any breast discharge, lumps, scaly nipples, pain, swelling, or redness.

Respiratory: She denies experiencing shortness of breath, wheezing, difficulty catching her breath, chronic cough, or sputum production.

Cardiovascular/Peripheral Vascular: She denies experiencing dizziness, chest pains/pressure/discomfort, palpitations, decreased exercise tolerance, or blue/cold fingers and toes.

Gastrointestinal: She denies experiencing nausea, vomiting, abdominal pain, constipation, diarrhea, dark tarry stool, bright red blood in her bowel movements, early satiety, or bloating.

Genitourinary: She denies any pain or burning sensation on urination. She denies noticing any blood in her urine or having difficulties starting or stopping urine stream. She denies history of dribbling, incontinence, urgency during the day or night, or nay changes in frequency.

Musculoskeletal: She has complaints of back pain that is present all the time, graded as 7/10 on pain scale and is sharp is character. She denies any problems with muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, swelling or redness, neck or shoulder pain, or hip pain.

Neurological: She denies experiencing fainting, dizziness, weakness, numbness, tingling or tremors, or seizures.  

Hematological: She denies easy bruising, bleeding gums, nose bleeds, or other sites of increased breathing.

Endocrine: She denies any problem with heat or cold intolerance, increased thirst, increased sweating, frequent urination, or changes in appetite.

Psychiatric: She denies any problems with nervousness, depression, lack of interest, sadness, memory loss or mood changes, or hearing or seeing things that are not there. Case Study For Patient Complaining Of Back Pain Assignment

Objective

General: Patient is A and Ox4

VS: Temp: 37.0 0C (oral), BP- 136/80 HR-88bpm (radial), RR-16bpm, O2 sat-96% RA, Height-66” Weight- 130.0lb, BMI-20.9

General Appearance: Gloria Jenkins is A and O x4, of good nutritional status, well-groomed, not in respiratory distress.

HEENT: There is no eye lid edema, the conjunctiva is pink, no discharge present. There is no hoarseness. The oropharynx is not injected, clear mucosa, tonsils without exudates. Tongue normal color, symmetrical. No swelling or ulcerations. Gag reflex present. The neck has no visible scars, deformities, or other lesions. Trachea is in the midline and freely mobile. No asymmetry or accessory muscle use with quiet breathing.

Skin/Integumentary: The skin is warm and dry.

Cardiovascular: Apex beat 5th intercostal space mid-clavicular line (MCL). Normal heart sounds.

Respiratory: The chest is symmetrical and the anterior-posterior diameter is normal. The excursion with respiration is symmetrical and there are no abnormal retractions or use of accessory muscle. No distention, scars, masses, or rashes. There is auscultated expiratory wheeze on the apical lobe on the right lungs and wide spread expiratory wheeze in the left lung.

Abdomen: On inspection, the abdomen is flat and symmetrical, with no scars, deformities, striae, or lesions. On palpation, the abdomen is soft and non-tender in all quadrants. There is no HSM, mass, herniation, or abnormal pulsations. It has present bowel sounds.

GU/Rectal: Normal external genitalia. No masses or tenderness. Normal pelvic exam. No visual fissure, induration, or lesions. Normal sphincter tone. No masses or tenderness, and guaiac negative.  Case Study For Patient Complaining Of Back Pain Assignment

Musculoskeletal: There is no swelling or deformity in the extremities. There is no edema, clubbing, or cyanosis. There is no tenderness, muscle resistance, rigidity, or deformity on palpation. There is normal muscle bulk and tone. There are no specific spinal process or paraspinal muscle tenderness, with the back and spine being non-tender to percussion.

Lymphatics: No pathological cervical, supraclavicular, axillary, or inguinal lymphadenopathy.

Neurological: Normal gait and posture. Normal bulk and tone and no muscle rigidity. No involuntary movements. Knee or patella reflex was 1 on the right knee and 2 on the left knee. The ankle or tendon Achilles reflex was 2 in both ankles. Light touch was slightly diminished in the right lower extremity along the anterolateral thigh past the knee to the medial aspect of the leg and foot. Normal ROM upper extremities. Straight leg raise abnormal at 45 degrees on the right with pain radiating down anterior leg below the knee. Contralateral straight leg raise test also positive with elevation of the left leg causing symptoms on the right. Unable to bend at the waist without significant pain. Right knee extension strength testing is 4/5 – limited by pain. Right hip extension strength testing is 4/5 limited by pain. All other muscle groups are 5/5 strength.

Assessment

  • Lumbar spine MRI
  • Spine X-ray

Primary Diagnosis and ICD-10 code

    • Disc herniation (M51.26): Disc herniation is a disease that occurs due to damage to the annulus fibrous which allows the nucleus pulposus, usually at the center of a vertebral disc, to herniate. The herniated disc causes compression of nerves or the spinal cord leading to neurological deficits (motor, sensory, or reflex deficits) (Dydyk, Massa, & Mesfin, 2021). The most common cause of this disease is degenerative disc diseases and trauma (Dydyk, Massa, & Mesfin, 2021). The disease can be managed conservatively with NSAIDs and physical therapy as the first line treatment modalities (Dydyk, Massa, & Mesfin, 2021)Case Study For Patient Complaining Of Back Pain Assignment. Other management options include epidural steroid injection and surgery for pain that is refractory to other management options.

Differential Diagnoses

    • Compression fracture (S32.000A): It refers to the  partial collapse of a vertebra that often occur following trauma to the spine, a fall, lifting heavy objects, or through weakening of the bone such as due to osteoporosis. The symptoms of this disease include back pain, loss of height, and a hunched-forward posture. Its management is often physiotherapy and analgesic for pain relief. Like disc herniation, surgery is only considered for severe debilitating symptoms of this disease.
    • Spinal neoplasm (C72.0): This refers to any malignant tumor occurring within the spine. These are the primary tumors that could occur within the spinal cord, excluding tumors of the meninges, autonomic nervous system, and peripheral nerves. However, all these neoplasms could lead to back pain, variable radiculopathy, and spinal cord compression syndrome.

Plan

  • Additional laboratory and diagnostic tests:
    • none
  • Consults:
    • Neurosurgical, radiological, and physician consultation for further evaluation and development of a definitive management (Dydyk, Massa, & Mesfin, 2021)Case Study For Patient Complaining Of Back Pain Assignment.
  • Therapeutic Modalities: Pharmacological And Nonpharmacological Management
    • Analgesic – Morphine sulfate intramuscular 5 mg STAT; Shift to tramadol 25 mg tablets once daily in the morning to be taken orally for a week. Dispense 7 tables.
    • Advise on adequate bed rest.
    • Monitor for severe or rapidly progressing neurological changes.
    • Start physical therapy after three weeks if symptoms persist.
    • Consider surgery as last resort for pain refractory to other management strategies (Dydyk, Massa, & Mesfin, 2021).
  • Social Determinants of Health (Sod)
    • Educate to stop smoking.
  • Health Promotion
    • Education on lifestyle modification to maintain a healthy weight and better control of her diabetes and hypertension.
    • Enrollment is appropriate hypertension or cardiovascular and smoking cessation programs.
    • Education to stop smoking.

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Education on better lifting mechanism and the need to reduce straining at work

    • Advice on the need for adequate bed rest and rest in between shifts
  • Patient education: Explanations and advice given to patient and family members.
      • Informed the patient that the disease is often self-limiting in most patients and that the symptoms will go away on their own within two to twelve weeks.
      • Advised on physical activity and diet modification to maintain a healthy weight.
      • Advised on the need to adhere to medication for better controlled BP and blood sugar levels.
      • Educated to stop smoking and advised to join smoking cessation programs.
      • Advised to minimize straining at work and apply good lifting body mechanics or techniques.
      • Advised to ensure adequate bed rest and to take adequate rests between shifts at work.
  • Disposition/follow-up instructions:
    • Upon discharge, follow up with the patient in a week to reevaluate pain levels and readjust or change medication as required to possible NSAIDs.
    • Referral to the physiotherapist after three weeks for physical therapy.

Reference

Dydyk, A., Massa, R., & Mesfin, F. (2021). Disk Herniation. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Case Study For Patient Complaining Of Back Pain Assignment