Week 5 Discussion Advance Nursing Apply information from the Aquifer Case Stud to answer the following discussion questions: Discuss the Mr. Payne’s his

Week 5 Discussion Advance Nursing Apply information from the Aquifer Case Stud 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 assessment 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?

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use references in apa style. case stud is attached 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 male truck driver complaining of two weeks of sharp, stabbing back pain after lifting a 10-lb. box. 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 POINT

Low Back Pain Prevalence, Cost, & Duration

Low back pain (LBP) is the fifth most common reason for all doctor visits. In the U.S., the 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 POINT

Common Causes of Back Pain

Musculoskeletal (MSK) and Non-MSK Causes of Back Pain

MSK Causes

Axial:

· Degenerative disc disease

· Facet arthritis

· Sacroiliitis

· Ankylosing spondylitis

· Discitis

· Paraspinal muscular issues

· SI dysfunction

Radicular:

· Disc prolapse

· Spinal stenosis

Trauma:

· Lumbar strain

· Compression fracture

Non-MSK Causes

Neoplastic:

· Lymphoma/leukemia

· Metastatic disease

· Multiple myeloma

· Osteosarcoma

Inflammatory:

· Rheumatoid Arthritis

Visceral:

· Endometriosis

· Prostatitis

· Renal lithiasis

Infection:

· Discitis

· Herpes zoster

· Osteomyelitis

· Pyelonephritis

· Prostatitis

· Spinal or epidural abscess

Vascular:

· Aortic aneurysm

Endocrine:

· Hyperparathyroidism

· Osteomalacia

· Osteoporotic vertebral fracture

· Paget disease

Gastrointestinal:

· Pancreatitis

· Peptic ulcer disease

· Cholecystitis

Gynecological:

· Endometriosis

· Pelvic inflammatory disease

Dr. Lee tells you: “Working from such a broad list is difficult. Having a shorter list of working diagnoses will help you conduct a more focused initial history and physical exam. What are the three most common causes of back pain?”

Degenerative joint disease

Disc herniation

 Lumbar strain

Dr. 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 distinguish the common causes for back pain (95% of cases) from the 5% with serious underlying diseases or neurologic impairments that are potentially treatable.”

You and Dr. Lee take a few minutes to review Mr. Payne’s chart:

Vital signs:

· Temperature is 37 °C (98.6 °F)

· Pulse is 80 beats/minute

· Respiratory rate is 12 breaths/minute

· Blood pressure is 130/82 mmHg

· Weight is 77 kgs (170 lbs)

· Body Mass Index is 24 kg/m2

Past Medical History: Diabetes, well-controlled. Hypertension, fair control. Hyperlipidemia, fair control.

Past Surgical History: None

Social History: Works as a truck driver, which involves lifting 9-16 kgs (20-35 lbs) 4 hours of the day, married with 2 daughters,

Habits: Smoked one pack per day for 20 years. Quit smoking two years ago, drinks one to two beers occasionally on the weekends, no history of IV drug use.

Medication:

· Metformin 1000 mg PO twice daily

· Glyburide 10 mg PO twice daily

· Amlodipine 2.5 mg PO daily

· Lisinopril 40 mg PO daily

· Simvastatin 40 mg PO daily

Allergies: No known drug allergies.

After 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 and became constant. 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, with 0 being no pain and 10 being the worst pain, 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 dose of ibuprofen and naproxen were you taking, how often, and for how many days?”

“I was taking ibuprofen 400 mg every six hours for three days and then I tried naproxen 250 mg once daily for five days.”

“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 Systems

Mr. Payne does not have numbness or weakness in his legs. The pain is better when he lies down. He has not had urinary frequency, dysuria, problems with bowel or bladder control, fever or chills, nausea or vomiting, or weight loss. He also reports no recent trauma or unrelenting night pain.

You excuse yourself from Mr. Payne to discuss your findings with Dr. Lee.

the top four diagnoses on your differential for low back pain in this patient.

Degenerative arthritis

Disc herniation

 Lumbar strain

Spondylolisthesis

Dr. Lee tells you, “On physical exam, you can discover problems with the bony structures and muscles of the spine through inspection of posture, contour, and symmetry, palpation of the bony prominences, and range of motion testing.

A solid understanding of the neurological exam of the lower extremity will help you determine if the pain is due to nerve impingement or from muscle and bone.”

You and Dr. Lee return to examine Mr. Payne together.

TEACHING POINT

Physical Exam for Back Pain—Standing

Throughout the whole exam make certain to note how your patient is sitting, standing, and walking in general, asking yourself, “What is his degree of impairment?” and “How uncomfortable is he?”

I. Inspection: Look at posture, contour, and symmetry. Also, inspect overlying skin to check for any lesions or abnormalities.

· Check for lordosis

· Check for kyphosis

· Check for scoliosis

Slight scoliosis may be more easily visualized during lumbar flexion. This is performed by having the patient stand with their feet and hands together, like they are about to dive off a diving board, bending forward toward their toes. Look out across the back to see if the shoulders are level.

II. Palpation: Check for any tenderness, tightness, rope-like tension, or inflammation in the paraspinous muscles or tenderness over bony prominences. This procedure checks for muscle spasms, vertebral fractures, or infection.

III. Range of Motion (ROM):

· Lumbar Flexion (normal is 90 degrees): This is the best measure of spine mobility. Restriction and pain during flexion are suggestive of herniation, osteoarthritis, or muscle spasm.

· Lumbar Extension (normal is 15 degrees): Pain with extension is suggestive of degenerative disease or spinal stenosis.

· Lateral Bending (normal is 45 degrees): Most patients should be able to touch the proximal fibular head of the knee. Pain on the same side as bending is suggestive of bone pathology, such as osteoarthritis or neural compression. Pain on the opposite side of bending is suggestive of a muscle strain.

· Rotation to the left and rotation to the right. Compare side to side.

· Range of motion may be varied due to the patient’s age and body habitus

IV. Gait: Ask the patient to walk on heels and toes. Expect normal gait, even with disc herniation.

· Difficulty with heel walk is associated with L5 disc herniation

· Difficulty with toe walk is associated with S1 disc herniation

V. Stoop Test: Have the patient go from a standing to squatting position.

In patients with central spinal stenosis, squatting will reduce the pain. However, asking the patient to run is not part of a back exam and may cause discomfort to the patient who is already in pain.

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 increased 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 reports no 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 5/5 strength throughout the lower extremities. His sensory exam is normal.

Pulmonary Exam: His lungs are clear on auscultation and percussion.

Cardiovascular Exam: His cardiac exam demonstrates a regular rhythm, no murmur or gallop.

Dr. Lee continues, “The final part of the exam is done in the supine position.”

What do you want to check while the patient is supine?

. Check for abdominal bruit, especially on older adult patients.

 Perform passive straight leg raise on all patients.

Exam—Supine

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 non-tender. 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 exam room for a moment.

What are your top two working diagnoses for Mr. Payne’s back pain?

Disc herniation, Lumbar strain

Based on physical exam, you believe that Mr. Payne has back pain with radiculopathy, likely at the L5/S1 level. Given his risk factor as a truck driver and pain radiating down his leg, Mr. Payne’s pain is likely due to disc herniation. However, lumbar strain is still a possibility.

Dr. Lee then asks you: “Which of the following findings would support the diagnosis of disc herniation?”

Pain worse with sitting

 Pain worse with cough and sneezing

Drop foot

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.”

What are the red flags or alarm symptoms that would suggest a more serious underlying condition causing his back pain?

Loss of bowel/bladder control

Severe pain that awakens the patient from sleep.

Weight loss

Fever

Mr. Payne does not have any red flags, so it is safe to wait to do any imaging or lab tests. Even with a disc herniation the pain often resolves on its own in six weeks, and no further workup is necessary.

While Dr. Lee takes the time to return to the exam room and review mechanical low back pain with Mr. Payne, she asks you to consider what other testing should be done at this time. Is an MRI indicated? no

While Dr. Lee takes the time to return to the exam room and review mechanical low back pain with Mr. Payne, she asks you to consider what other testing should be done at this time. Is an MRI indicated? Mr. Payne has no red flag symptoms to suggest an urgent need for imaging. Given that most radicular back pain, such as he has, resolves on its own within a month, it is most appropriate to avoid imaging in this situation.

“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.”

Which of the following are indicated at this time?

 Prescribe NSAID and muscle relaxant

Moist heat

 Referral to physical therapy

Would physical therapy be helpful for Mr. Payne?

Yes, There is some data to show that tailored physical therapy is slightly more effective for acute back pain compared to patients who just stay active. At four weeks, patients who received physical therapy had 10-point improvement in a 100-point disability score compared to the control group. There is great variation in physical therapy because various interventions (exercises, traction, massage) and different modalities (heat, ice, ultrasound) may be used. There is also evidence that spinal manipulation is safe and can help in the short term.

You 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, and he is given a limited supply for seven days. Dr. Lee tells Mr. Payne about the side effects of both naproxen and codeine. 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.

Mr. Payne asks Dr. Lee: “What’s the likelihood that this pain will go away completely?”

 Longer time to recovery is associated with older patients.

Most back pain is improved in 4 to 6 weeks.

Recurrence rate for back pain varies from 35% to 75%.

Three weeks later, Mr. Payne returns for his follow-up appointment and you discover the following:

Pertinent History

Mr. 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 Findings

Vital signs: stable

Neurologic: 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.

One week later, Mr. Payne returns for follow-up. You review the results of the MRI report.

MRI report:

1. 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.

2. 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 the S1 nerve root due to a large herniated disc at L5-S1.

What are the treatment options for Mr. Payne?

 Acupuncture

 It has only been five weeks, continue with current treatment

Osteopathic manipulation

 Surgery

Mr. Payne would rather defer surgery if he can. Options for Mr. Payne now include continuing more conservative treatment or manual therapy—usually given by an osteopathic physician or chiropractor—or a trial of acupuncture.

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.

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