1. Dq 1 week 5 | Nursing homework help
this dq is due for tomorrow 08/18/18 You are working with Dr. Lee today. She hands you a
triage note from the nurse regarding your next patient, Mr. Payne:Forty-five-year-old white
male truck driver complaining of two weeks of sharp, stabbing back pain. The pain was
better after a couple of days but then got worse after playing softball with his daughter. This
morning his pain is so bad that he had trouble getting out of bed.Dr. Lee provides you some
background information about low back pain.TEACHING POINTLow Back Pain Prevalence,
Cost, & DurationLow back pain (LBP) is the fifth most common reason for all doctor visits.
In the U.S., lifetime prevalence of LBP is 60% to 80%. The direct and indirect costs for
treatment of LBP are estimated to be $100 billion annually. Fortunately, most LBP resolves
in two to four weeks.Dr. Lee continues: “There are many causes for LBP. For presenting
symptoms that have a broad differential diagnosis, I find it helpful to think of systems of
etiologies in which diseases or conditions can be categorized.”TEACHING POINTCommon
Causes of Back PainMusculoskeletal (MSK) and Non-MSK Causes of Back PainMSK
CausesAxial:Degenerative disc diseaseFacet arthritisSacroiliitisAnkylosing
spondylitisDiscitisParaspinal muscular issuesSI dysfunctionRadicular:Disc prolapseSpinal
stenosisTrauma:Lumbar strainCompression fractureNon-MSK
CausesNeoplastic:Lymphoma/leukemiaMetastatic diseaseMultiple
myelomaOsteosarcomaInflammatory:Visceral:EndometriosisProstatitisRenal
lithiasisInfection:DiscitisHerpes zosterOsteomyelitisPyelonephritisSpinal or epidural
abscessVascular:Endocrine:HyperparathyroidismOsteomalaciaOsteoporosisPaget
diseaseDr. Lee suggests, “Now, let’s look a bit more at the risk factors for mechanical low
back pain that you can review with Mr. Payne during your history.”Dr. Lee continues, “The
major task in treating back pain is to Now that you have a diagnosis of disc herniation with
radiculopathy for Mr. Payne, let’s discuss what would you like to do for him distinguish the
common causes for back pain (95% of cases) from the 5% with serious underlying diseases
or neurologic impairments that are potentially treatable.”TEACHING POINTRisk Factors for
Low Back PainProlonged sitting, with truck driving having the highest rate of LBP, followed
by desk jobsDeconditioningSub-optimal lifting and carrying habitsRepetitive bending and
liftingSpondylolysis, disc-space narrowing, spinal instability, and spina bifida
occultaObesityEducation status: low education is associated with prolonged illnessPsycho-
social factors: anxiety, depression stressors in lifeOccupation: Job dissatisfaction, increased
manual demands, and compensation claimsTEACHING POINTRed Flags For Serious Illness
or Neurologic Impairment with Back PainFeverUnexplained weight lossPain at nightBowel
2. or bladder incontinenceNeurologic symptomsSaddle anesthesiaHISTORYYou and Dr. Lee
take a few minutes to review Mr. Payne’s chart:Vital signs:Temperature: 98.6°
FahrenheitHeart rate: 80 beats/minuteRespiratory rate: 12 breaths/minuteBlood pressure:
130/82 mmHgWeight: 170 poundsBody Mass Index: 24 kg/m2Past Medical History:
Diabetes, well controlled. Hypertension, fair control. Hyperlipidemia, fair control.Past
Surgical History: NoneSocial History: Works as a truck driver, which involves lifting 20-35
lbs 4 hours of the day, married with 2 daughters,Habits: Quit smoking two years ago, drinks
1 to 2 beers occasionally on the weekends, no history of IV drug use.Medication:metformin
500mg 2 twice dailyglyburide 5mg 2 twice dailyamlodipine 2.5 mg dailylisinopril 40 mg
dailysimavastin 40 mg dailyAllergies: No known drug allergiesAfter introducing yourself to
Mr. Payne, you sit down across from him and begin your history, focusing on the key
elements.“Can you tell me about your back pain?”“As I told the nurse, the pain started two
weeks ago after I lifted a box at work. Right away, I got this sharp pain on the left side of my
back. The box wasn’t even that heavy.“I talked to the nurse at work; she said to ice it and to
take ibuprofen. It got better after three days. But, I was playing softball with my daughter
last weekend, and the pain came back. This time it was worse than before. This week, the
pain is so bad I can hardly get out of bed. I get a sharp pain in my back which goes down my
left leg to my ankle.”“On a scale of 0 to 10, 10 being the worst, how severe is the pain?”“It’s
probably a 7.”“Have you found anything that improves the pain?”“Ibuprofen and Naproxen
worked at first, but they are not helping much anymore.”“What about positions that make
things better or worse?”“The pain is worse with any movement of my back or sitting for a
long time. It is better when I lie down.”“Have you had back pain before?”“Yes, I have back
pain from time to time. But I’m usually better after 2 to 3 days. This is the worst pain I have
ever had.”You complete your history with a review of systems and discover:Review of
SystemsMr. Payne does not have numbness or weakness in his legs. The pain is better when
he lies down. He denies urinary frequency, dysuria, problems with bowel or bladder control,
fever or chills, nausea or vomiting, or weight loss. He denies any specific trauma, except for
when he lifted a 10-pound box at work. He denies unrelenting night pain.You excuse
yourself from Mr. Payne to discuss your findings with Dr. Lee.Dr. Lee walks through the
steps for completing a neurologic exam in a patient with back pain.Back Exam –
Standing:Mr. Payne has normal curvature, tenderness on palpation on the left lumbar
paraspinous muscle with increase tone. Full range of motion, but has pain with movement.
His gait is normal. He can walk on his heels and toes. He can do deep knee bends.Back Exam
– Seated:Mr. Payne denies feeling pain when checked for CVA tenderness. He has no pain in
his right leg with the modified version of SLR. While he does not exhibit a true tripod sign,
he does complain of pain when his left leg is raised. Mr. Payne’s reflexes are 2+ and equal at
the knees and 1+ at both ankles. The motor exam reveals no weakness of the muscles of the
lower extremities. His sensory exam is normal.Pulmonary Exam: His lungs are
clear.Cardiovascular Exam: His cardiac exam demonstrates a regular rhythm, no murmur or
gallop.Mr. Payne’s abdominal exam is negative. His straight leg raising is positive at 75
degrees on the left and negative on the right. His FABER test is negative and sacroiliac joint
is nontender. His motor exam reveals no weakness of the muscles of the lower
extremities.After finishing your exam together, you and Dr. Lee excuse yourselves from the
3. exam room for a moment.Dr. Lee reminds you that disc herniation, a condition which is self-
limited and usually resolves in two to four weeks, remains a working diagnosis for Mr.
Payne. She says, “Let’s take a few minutes, though, to discuss some conditions we still don’t
want to miss.”Now that you have a diagnosis of disc herniation with radiculopathy for Mr.
Payne, let’s discuss what would you like to do for himYou and Dr. Lee now return to Mr.
Payne’s exam room to talk about treatment options with him. Dr. Lee tells Mr. Payne to
avoid strenuous activities but to remain active. Dr. Lee increases the dosage of naproxen to
500 mg BID to take with food. Since his pain is intense (7/10), he is given a prescription for
acetaminophen with codeine to take at night, when his pain is severe. Mr. Payne declines a
muscle relaxant because they usually make him drowsy. He would like to be referred to
physical therapy as it was helpful in the past.Three weeks later, Mr. Payne returns for his
follow-up appointment and you discover the following:Pertinent HistoryMr. Payne has had
little relief with the treatment prescribed. He is frustrated that he has been in pain for more
than a month. His pain has been progressively worse. It radiates down the lateral part of his
left leg and side of his left foot. This pain is worse than the back pain. He does not have any
problems with bowel or bladder control and there is no weakness of his leg.Pertinent Exam
FindingsVital signs: stableNeurologic: Normal gait, but moves slowly due to pain; range of
motion is full, with pain on flexion; SLR is positive at 45 degree on the left; motor strength
intact; reflexes 2+ bilaterally at the knees, absent at the left ankle, 1+ at the right ankle.Dr.
Lee agrees with your diagnosis of radiculopathy of S1 nerve root with progression. She
orders an MRI and sets up an appointment to see Mr. Payne after the MRI.ne week later, Mr.
Payne returns for follow-up. You review the results of the MRI report.MRI report: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.You review the findings with Dr. Lee. She agrees with your diagnosis of
radiculopathy of S1 nerve root due to a large herniated disc at L5-S1.You call Mr. Payne two
weeks later to see how he is doing. He reports that he is doing quite a bit better. He went to
an osteopathic physician who did some manual therapy and started him on a strict walking
program. He is very encouraged and plans on losing weight through exercise and
diet.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?
