Apply information from the Aquifer Case Study to answer the following discussion questions:
- Discuss the Mr. Payne’s history that would be pertinent to his genitourinary problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
- Describe the physical exam and diagnostic tools to be used for Mr. Payne. Are there any additional you would have liked to be included that were not?
- Please list 3 differential diagnoses for Mr. Payne and explain why you chose them. What was your final diagnosis and how did you make the determination?
- What plan of care will Mr. Payne be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
- EXAMPLE IS UPLOAD
NSG 6001 Week 5 Discussion
Patient Initials: MP
Subjective Data: The patient presents to the clinic with complaints of sharp, stabbing lower back pain that radiates down his left leg for the past 2 weeks. The patient states his pain was worsened with sport activity and he had difficulty getting out of bed the morning of his visit.
Chief Compliant: Mr. Payne states he is having “sharp and stabbing pain on the left side of his back” after he lifted a box 2 weeks ago. He states the pain got better after three days but it returned after playing softball. MP states his pain is causing him to have “trouble getting out of bed”.
History of Present Illness: MP is a 45-year-old male with complaints of lower back pain. Mr. Payne past medical history includes having diabetes, hypertension, and hyperlipidemia. The patient states his diabetes is well under control, however, he has fair control of his blood pressure and cholesterol levels.
Onset: 2 weeks ago
Location: Lower back on the left side; radiates down left leg
Duration: Intermittent chronic back pain
Characteristics: Sharp and stabbing
Aggravating factors: Activity, lifting, sitting for a long period of time
Relieving factors: Pain is better when he lies down
Treatment: Ice, Ibuprofen, Naproxen
Severity: Patient describes severe lower back pain where he is unable to get out of bed. Patient states his pain is a 7 out of 10 on approved pain scales.
PMH/Medical/Surgical History: MP denies any surgical history or drug allergies. The patient’s medications include: Metformin 500mg 2 twice daily, Glyburide 5mg 2 twice daily, Amlodipine 2.5mg daily, Lisinopril 40mg daily, and Simvastatin 40mg daily.
Significant Family History: MP denies family history of inheritable diseases
Social History: Mr. Payne works as a truck driver and he lifts about 20 to 35 pounds about 4 hours during his work days. The patient states he is married and has 2 daughters. MP states that he quit smoking 2 years ago. He also admits to drinking 1 to 2 beers occasionally on the weekends. The patient denies recreational drug use.
Review of Symptoms:
General: MP denies fever, chills, weight loss, or specific trauma except when lifting 10- pound box at work.
Integumentary: Denies skin changes.
HEENT: Denies headache, vision changes, nose or ear changes, sore throat or trouble swallowing.
Cardiovascular: Denies chest pain, palpitations, edema, or shortness of breath.
Respiratory: Denies shortness of breath.
Gastrointestinal: Denies nausea, vomiting, changes in bowel habits, or bowel incontinence.
Genitourinary: Denies dysuria, change in frequency, or problems with bladder control.
Musculoskeletal: Positive for lower back pain radiating down left leg.
Neurological: Patient denies numbness or weakness in legs.
Endocrine: Denies polydipsia or polyuria.
Hematologic: Denies bruising, bleeding, or infections.
Psychologic: Denies depression, anxiety or sleeping problems.
Objective Data:
Vital Signs: BP –130/82 mmHg ; P – 80 beats/min, regular ; R – 12 breaths/min; T – 98.6 Fahrenheit; Wt. – 170 pounds; BMI – 24 kg/m2
Physical Assessment:
General: Well-appearing 45-year-old male in moderate distress. A&O x 3
Integumentary: No rash, unusual bruising, or prominent lesions
HEENT: Normocephalic; PERRLA; No thyromegaly, adenopathy or masses noted.
Lymph Nodes: No lymphadenopathy noted
Lungs: Bilaterally clear lungs to auscultation without wheezes, rales, or rhonchi.
Heart: Regular heart rate and rhythm, no murmurs, rubs, or gallops. No edema.
Abdomen: Soft, non-tender, without organomegaly or masses. Normoactive bowel sounds heard in four quadrants.
Rectum: Normal sphincter tone, no hemorrhoids or masses palpable Extremities/Pulses: Warm and well-perfused, no cyanosis, clubbing, or edema.
Musculoskeletal: Normal curvature of the spine; Tenderness on palpation of left lumbar paraspinous muscle with increased tone; Normal gait, but moves slowly due to pain. Full range of motion with pain on flexion.
Neurologic: Straight leg raise (SLR) test is positive at 45 degrees on the left leg; Motor strength intact; Reflexes 2+ bilaterally at the knees, absent at the left ankle, 1+ at the right ankle
Laboratory and Diagnostic Test Results:
MRI of spine after progression of pain (Abnormal)
- Moderate-size, herniated disc at L5-S1 with associated marked impingement on the left S1 nerve root and mild to moderate impingement on the right S1 nerve root. There is mild central canal stenosis.
- Annular tear with a small central disc herniation at L4-5 causing mild central canal stenosis.
A magnetic resonance imaging (MRI) study is the most commonly used diagnostic tool for low back pain (Buttaro, Trybulski, Polgar-Bailey & Sandberg-Cook., 2017). The MRI scan was ordered after Mr. Payne continued to have persistent back pain after physical therapy and increasing his Naproxen medication. Other diagnostic tools include an x-ray, radionuclide bone scintigraphy and computed tomography (CT) scan. Bone scintigraphy is useful if osteomyelitis, bone neoplasms, or occult fractures are suspected (Buttaro et al., 2017). CT scans are helpful to assess degenerative disorders and if an MRI is contraindicated. Laboratory tests, including an erythrocyte sedimentation rate (ESR) and a C-reactive protein, should also be considered to measure inflammatory activity (Fischbach & Dunning, 2015).
Assessment:
- Low back pain, M54.5
- Lumbar strain, S39.012A
- Disc herniation, M51.27
- Spinal stenosis, lumbosacral region, M48.07
MPs occupational history, clinical presentation, and MRI results all correlate to the diagnosis of low back pain due to his lumbar strain, disc herniation, and spinal stenosis. A lumbar strain is an injury to the lower back which results severe low back pain (Johns Hopkins Medicine, 2018). Lifting heavy objects or sport activities that require twisting of the lower back like softball can increase the patient’s risk for this type of injury (Johns Hopkins Medicine, 2018). Spinal stenosis is a narrowing of the spaces within the spine that can put pressure on nerves and cause pain, tingling, numbness, and muscle weakness (Mayo Clinic, 2018). Mr. Payne’s MRI results also correlate with spinal stenosis in the lumbosacral region.
Plan of Care:
The conservative regimen for low back pain and disc herniation management is physical and pharmacological therapy. Exercise interventions based on individual needs has been shown to decrease patient’s pain and reduce medication use (Buttaro et al., 2017). Disc herniation’s specifically respond better to extension-based exercise programs. Core strengthening can also promote lumbar stability by providing dynamic support (Buttaro et al., 2017). Modalities used during physical therapy include ice, superficial heat, ultrasound, transcutaneous electrical nerve stimulation (TENS), and traction (Buttaro et al., 2017). Complementary and alternative therapies that can be attempted include yoga, acupuncture, chiropractic manipulation, and massage therapy (Buttaro et al., 2017; Mayo Clinic, 2018).
Medications used for low back pain management usually start with nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen. As discussed in the patient’s medical history, he has already used Ibuprofen and Naproxen over the counter. The increased dosage of an NSAID for short term pain management is appropriate. It should be discussed with the patient that he should not stay on NSAIDs long term because it may cause gastrointestinal adverse events and renal injury (Medscape, 2018). Skeletal muscle relaxants, such as cyclobenzaprine, can be added to the patient’s regimen to reduce back spasms. If the patient fails to respond to initial treatment, opioid analgesics may be prescribed to treat acute exacerbations. However, opioids are powerful pain killers that may be addictive (Medscape, 2018). Florida’s law regarding opioid prescription drugs for the treatment of acute pain may not exceed a 3-day-supply, however, a 7-day-supply may be prescribed if the prescriber documents that they believe a 3-day-supply is not sufficient to treat the patient’s medical condition (MyFloridaHouse.gov, CS/CS/HB 21, p. 16). Anticonvulsants, like Gabapentin, has also shown to be beneficial for radiating nerve pain, but it may cause drowsiness, dry mouth and dizziness (Buttaro et al, 2017; Mayo Clinic, 2018; Medscape, 2018). Cortisone epidural injections may also be considered to reduce swelling and inflammation in the area around the spinal nerves (Mayo Clinic, 2018). Symptoms of radiculopathy and spinal stenosis can indicate a need for epidural injections (Buttaro et al., 2017).
MP should be educated on mechanical low back pain and that most cases will resolve over time. The patient should be taught to maintain an ideal body weight and proper body mechanics to prevent worsening of pain or recurrence of back pain episodes. The patient should be referred to a spine specialist or an orthopedic spine surgeon if the pain is persistent, severe and functionally limiting or if the patient experiences progressive weakness or neurologic deficits (Buttaro et al., 2017). MP must be aware of issues that necessitate medical evaluation such as new limb weakness, or change in bowel or bladder function (Buttaro et al., 2017).
References
Buttaro, T.M., Trybulski, J., Polgar-Bailey, P. & Sandberg-Cook, J. (2017). Primary care: A collaborative practice. (5th ed.). St. Louis, M.I.: Elsevier
Fischbach, F. & Dunning, M.B. (2015). A manual of laboratory and diagnostic tests. (9th ed.). New Delhi: Wolters Kluwer Health
Johns Hopkins Medicine. (2018). Lumbar strain. Retrieved from: https://www.hopkinsmedicine.org/healthlibrary/conditions/adult//mens_health/lumbar_str ain_85,P00947
Mayo Clinic. (2018). Herniated disk. Retrieved from: https://www.mayoclinic.org/diseases- conditions/herniated-disk/diagnosis-treatment/drc-20354101
Mayo Clinic. (2018). Spinal stenosis. Retrieved from: https://www.mayoclinic.org/diseases- conditions/spinal-stenosis/symptoms-causes/syc-20352961
Medscape. (2018). Cyclobenzaprine. Retrieved from: https://reference.medscape.com/drug/flexeril-amrix-flexmid-cyclobenzaprine-343338#4
Medscape. (2018). Naproxen. Retrieved from: https://reference.medscape.com/drug/aleve- anaprox-naproxen-343296#5
Medscape. (2018). Opioid abuse. Retrieved from: https://emedicine.medscape.com/article/287790-overview
MyFloridaHouse.gov. (2018). CS/CS/HB 21: Controlled substances. Retrieved from: http://myfloridahouse.gov/Sections/Documents/loaddoc.aspx?FileName=_h0021er.docx &DocumentType=Bill&BillNumber=0021&Session=2018
Response 1
Hi Trevor,
Great job on your discussion! I agree with the differential diagnoses that you determined. Johns Hopkins Medicine (2018) describes lumbar strain as an injury to the lower back which usually results in severe lower back pain. Mr. Payne’s occupation involves heavy lifting and sitting for long periods of time which may aggravate his condition. He also mentioned his pain reoccurring when playing softball. Lifting heavy objects or sport activities that require twisting of the lower back like softball can increase the patient’s risk for this type of injury (Johns Hopkins Medicine, 2018). My differential diagnoses included lumbar strain, disc herniation, and spinal stenosis based on Mr. Payne’s history, clinical presentation, and his magnetic resonance imaging result. A magnetic resonance imaging (MRI) study is the most commonly used diagnostic tool for low back pain (Buttaro, Trybulski, Polgar-Bailey & Sandberg-Cook., 2017). Mr. Payne’s MRI impression showed disc hernation in L4-L5 and L5-S1, mild central canal stenosis, and impingement on the S1 nerve root. This radiologic finding correlates with the differential diagnoses discussed above.
References
Buttaro, T.M., Trybulski, J., Polgar-Bailey, P. & Sandberg-Cook, J. (2017). Primary care: A collaborative practice. (5th ed.). St. Louis, M.I.: Elsevier
Johns Hopkins Medicine. (2018). Lumbar strain. Retrieved from: https://www.hopkinsmedicine.org/healthlibrary/conditions/adult//mens_health/lumbar_str ain_85,P00947
Response 2
Hi Yoandris,
In Mr. Payne’s case, it is imperative that the health care provider obtain a thorough health history and physical exam in order to determine an accurate diagnosis. Routine imaging of patients with acute or nonspecific low back pain is not recommended by the American Academy of Family Physicians, American College of Physicians, and American Pain Society because it does not necessarily improve patient outcomes and it may expose patients to unnecessary radiation (Buttaro, Trybulski, Polgar-Bailey & Sandberg-Cook, 2017). As you have stated, the FABER test and straight leg test (SLR) should be assessed to evaluate the flexion, extension, lateral flexion, and rotation of the lumbar spine for changes in symptoms throughout the movements (Buttaro et al., 2017). Mr. Payne’s SLR was positive at 45 degrees. Buttaro et al. (2017) states that a positive SLR test indicates that a nerve root impingement from a herniated disk is likely. A non-steroidal anti-inflammatory drug is recommended as the initial medication for pain management, but the patient may require other pharmaceutical agents such as muscle relaxants, anticonvulsants, cortisone injections, or narcotics if his pain worsens (Mayo Clinic, 2018). It may also be necessary to refer the patient to an orthopedic spine specialist if conservative treatments fail to improve his symptoms or if the patient experiences numbness/weakness, difficulty standing or walking, or loss of bladder or bowel control (Mayo Clinic, 2018). It is essential that Mr. Payne understand these symptoms so he knows when to seek medical attention.
References
Buttaro, T.M., Trybulski, J., Polgar-Bailey, P. & Sandberg-Cook, J. (2017). Primary care: A collaborative practice. (5th ed.). St. Louis, M.I.: Elsevier
Mayo Clinic. (2018). Herniated disk. Retrieved from: https://www.mayoclinic.org/diseases- conditions/herniated-disk/diagnosis-treatment/drc-20354101
