Lumbar radiculopathy and SI joint dysfunction
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The document summarizes demographic and assessment findings for a 60-year-old female patient named Muktaben Patel who presented with right lower back and leg pain, tingling, and numbness. She has been experiencing pain for 2 months that is aggravated by forward bending and relieved by lying down. On examination, she had tenderness in her lower back, muscle spasms, reduced range of motion, sensory changes, and positive orthopedic tests indicating lumbar and sacroiliac involvement. The diagnosis is lumbar spondylosis, radiculopathy at L5S1, and sacroiliac joint dysfunction.
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APA format with intext citation
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Initials, MF Age: 46-year-old Sex: Female, Caucasian.
S.
CC : “My Ankles Hurts, worse on the right ankleâ€.
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Respond by analyzing Analyze the possible conditions from your colleagues' differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.
APA format with intext citation
2 to 3 scholarly references with in the last 5 years
Plagiarism free with Turnitin report
250-300 minimum word count
Case scenario # 1
Week 8, Mpofu Sibongile C
1/18/2023
Review of Case Study # 2 Ankle Pain SOAP Note.
Patient Information: Name: MF
Initials, MF Age: 46-year-old Sex: Female, Caucasian.
S.
CC : “My Ankles Hurts, worse on the right ankleâ€.
HPI : MF is a 46-year-old Caucasian female who presents to the clinic this morning with bilateral ankle pain, worse on the right foot it hurts and very uncomfortable. She reports pain started two days ago after playing soccer over the weekend, she says she heard a “popâ€. It is a throbbing pain, that gets worse when she bears weight on it when standing or walking but gets better when she applies ice and rest with feet elevated. She states the pain as constant all day, associated with swelling. She rates her pain as 3/10 left ankle but right ankle is 7/10.
Current Medication:
1. Ibuprofen 400 mg x 2 PO 8 hrly prn for pain. Has been taking it for 2 days ago.
2. Tylenol 650 mg PO 6 hourly for pain. Since last night.
3. Ice packs, twice daily for pain.
4. Fish oil 1200 mg PO, HS for pain
Allergies: No Known allergies to drugs nor food allergies .
PMH: MF is up to date with her immunization, has covid-19 vaccine in June 2022. (Pfizer). Second dose on September 15th, 2022. Tetanus vaccine a year ago but cannot recall the date. Is getting flu vaccine end of the month. Made up history. Sprained her ankle 2 years ago,2020. No previous surgeries.
Soc History : Â She is a high school sports teacher. Married for 6 years, no children. She enjoys outdoor activities walking, camping, playing soccer and shopping. She lives with her husband in a 3-bedroom house, secure community. She does not smoke but drinks alcohol, a glass of wine during dinner and beer during weekends only if no sports. Denies drugs use. She drives herself to work, wears seat belts, she only answers the phone using her Bluetooth. She eats healthy diet and exercises 3 times a week on her treadmill and plays sports (soccer) every Friday afternoon and Saturday from 4 pm to 6pm. She gets support from her husband and is a member of teachers support group.
Fam Hx :
1. Mother: 72 years. Type 2 diabetes, on diet control, diagnosed 3 years ago alive.
2. Father: Father 78 years with gout, is alive.
3. Sister: 40 years with arthritis alive
4. Maternal grandmother: died at 80 years from hypertension.
5. Maternal grandfather: died at 68 years from COPD.
6. Paternal grandfather: Died from heart attack at 70 years.
7. Paternal grandmother: died at 80 years, unknown cause, but had arthritis.
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Lumbar radiculopathy and SI joint dysfunction
- 2. Demographic data Name: Muktaben patel Age: 60 years Gender: female Occupation: house wife Address: Ognaj
- 3. Demographic data cont... Refferd by : self Chief complain: patient has pain in right lower back to anterior aspect of leg and feet. - tingling and numbness present in anterior aspect of leg and feet.( right side).
- 4. Date of assessment: 8/7/2021 Present history:patient having pain in right lower back to right side lower limb. Tingling and numbnese is present.
- 5. Past history: pain started since 2 month. Personal history:not significant. Medical and surgical history : not present.
- 6. Pain assessment Mode of onset:gradual Pain site: right side lower back pain to right limb. Pain duration: since 2 month.
- 7. Type of pain: dull aching Aggravating factor : forward bending Relieving factor lying position and extension Intensity of pain: taking vas scale
- 9. Observation Body built: mesomorphic Gait: Normal Posture : Normal
- 10. Palpation Tenderness: Right lower back Spasm: right side illiopsoas & hamstring muscle spasm. _ left side illiopsoas and hamstring muscle spasm
- 11. Examination ROM : hip flexion = 0 to 110 hip extension = 0 to 20 hip abduction= 0 to 45 hip adduction = 0 to30 Knee flexion = 0to135 Knee extension=135 to 0
- 12. Right left MMT : hip flexors 4 4+ hip abductors 3+ 4 Knee flexors 5 5 Knee extensors 5 5 Ankle planter flexors 5 5 Ankle dorsiflexors 5 5
- 13. Calf muscle tightness b/l Sensory examination : sensation loss on planter aspect in both great toe. Sometimes no feel sensation on sole of foot. Myotomes : Normal L1,L2 hip flexion • L3 knee extension • L4 ankle dorsiflexion • L5 great toe extension
- 14. RIght left LLD :ASIS to medial 37inch 37 inch Malleolus Pelvic squaring: umbilicus to ASIS level both side Same and both ASIS Level equal.
- 15. Special test SLR test Right side +ve Left side - ve
- 21. • Faber test +ve • Aprroximation test + ve • Thigh thrust test +ve • Sacroilliac rocking test +ve • Gapping test +ve
- 22. Diagnosis • Lumbar Spondylosis • Lumbar radiculopathy • L5S1 pathology • Sacroilliac joint dysfunction