CASE STUDY: Tina Williams "Low Back Pain" i-HuMAN, Assignments of Nursing

Download CASE STUDY: Tina Williams "Low Back Pain" i-HuMAN and more Assignments Nursing in PDF only on Docsity! lOMoARcPSD|28578405 CASE STUDY: Tina Williams "Low Back Pain" i-HuMAN Patient Profile: Tina is a 52-year-old male who presents to the primary care clinic with complaints of low back pain. He reports that the pain started a few weeks ago and has been gradually worsening. He describes the pain as a constant ache that is present in his lower back and sometimes radiates down his right leg. The pain is worse with standing and walking and is relieved when he lies down. The patient reports no history of trauma or injury to the back, and he denies any weakness or numbness in his legs. He has tried over-the-counter pain medication, which provides some relief, but the pain persists. Initial Assessment: Upon examination, the patient is alert and oriented, with a heart rate of 80 beats per minute, a blood pressure of 130/80 mmHg, and a respiratory rate of 16 breaths per minute. His lower back is tender to palpation, and he has limited range of motion. Straight leg raise test is positive on the right side, which reproduces the pain in the leg. Neurological examination of the lower extremities is normal, with no weakness or sensory deficits. Case Questions with solutions: 1. What additional questions would you ask the patient to gather more information about his low back pain? • You could ask about the timing and onset of the pain, as well as any exacerbating or relieving factors. • You could ask about the patient's occupation and physical activities, as well as any recent changes in his work or exercise routine. • You could ask about the presence of any previous back pain or injuries. • You could ask about the patient's medical history, including any chronic medical conditions or medications that may be contributing to the pain. lOMoARcPSD|28578405 2. What physical exam maneuvers would you perform to further assess the patient's low back pain? To further assess the patient's low back pain, several physical exam maneuvers could be performed, including: • Thorough Musculoskeletal Exam: This exam includes palpation, range of motion, and other maneuvers that evaluate the patient's posture, alignment, and musculoskeletal structure. It is important to assess the patient's back muscles and ligaments for tenderness, swelling, or signs of inflammation. • Straight Leg Raise Test: This test involves lifting the patient's leg while keeping the knee straight. A positive test reproduces the patient's pain, which suggests nerve root irritation. • Neurological Assessment: The examiner should evaluate for any signs of neurological deficits, such as weakness or sensory loss in the legs. Sensory loss may include decreased sensation to light touch, pinprick, or temperature. • Muscle Spasms or Trigger Points Evaluation: The examiner should evaluate for any muscle spasms or trigger points that may be contributing to the pain. This may include assessing the patient's muscle strength, as well as the presence of any tender points or knots. • Gait Assessment: The examiner should observe the patient's gait for any abnormalities, such as limping or antalgic gait. Overall, a thorough physical examination is crucial to accurately diagnose and manage low back pain. It helps to identify the underlying cause of the pain, as well as to rule out other potential causes. 3. What are your top three differential diagnoses for this patient's low back pain? Low back pain can have various causes, and a differential diagnosis involves considering different possible conditions that can cause similar symptoms. The top three differential diagnoses for this patient's low back pain are: • Lumbar disc herniation: A herniated disc occurs when the soft inner material of a spinal disc bulges out and puts pressure on surrounding nerves. lOMoARcPSD|28578405 have ordered? • Lumbar spine X-rays: As mentioned, the risks of this test are minimal. However, there is a small risk of radiation exposure, which is generally considered safe in small doses. The benefits of this test include the ability to evaluate bony abnormalities or alignment issues. X-rays can show bone spurs, fractures, or signs of arthritis. • MRI: This test is generally considered safe, as there is no exposure to radiation. However, there are some risks associated with the use of strong magnetic fields, such as metal objects becoming dislodged and causing injury or interfering with the imaging. The patient must lie still for an extended period, and the test can be claustrophobic for some patients. The benefits of this test include the ability to assess for disc herniation or spinal stenosis. MRI can provide detailed images of the soft tissues and nerves in the back, allowing for a more accurate diagnosis. • EMG: The risks of this test are minimal, with some discomfort during the procedure. The benefits include the ability to evaluate for nerve impingement or muscle dysfunction. EMG involves inserting a small needle electrode into the muscles to measure their electrical activity. This test can help diagnose nerve or muscle disorders, such as sciatica or muscular dystrophy. It's important to note that the risks and benefits of each test may vary depending on the patient's individual health status and any underlying medical conditions. The ordering physician should discuss the potential risks and benefits of each test with the patient before proceeding. 7. What is your management plan for this patient, including any medications or procedures you would recommend? lOMoARcPSD|28578405 If the patient is diagnosed with degenerative disc disease, the following management options may be considered: • Nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen to manage pain • Muscle relaxants to alleviate muscle spasms • Corticosteroid injections to reduce inflammation and pain • Spinal decompression surgery to alleviate pressure on the affected nerve roots, if conservative management fails If the patient is diagnosed with lumbar disc herniation, the following management options may be considered: • Bed rest for a short period to allow the body to heal • NSAIDs, acetaminophen, or muscle relaxants to manage pain • Corticosteroid injections to reduce inflammation and pain • Physical therapy to help strengthen the muscles of the lower back and improve range of motion • Surgery to remove the herniated disc or alleviate pressure on the affected nerve roots, if conservative management fails If the patient is diagnosed with lumbar spinal stenosis, the following management options may be considered: • NSAIDs, acetaminophen, or muscle relaxants to manage pain • Corticosteroid injections to reduce inflammation and pain • Physical therapy to help improve range of motion and strengthen the muscles of the lower back • Surgery to alleviate pressure on the affected nerve roots, if conservative management fails. This may involve a decompression surgery or spinal fusion. It is important to note that the management plan for any patient should be tailored to their specific needs and medical history. The patient should also be closely monitored and their treatment plan should be adjusted as needed lOMoARcPSD|28578405 based on their response to treatment. 8. How would you follow up with this patient to monitor his progress and ensure appropriate treatment? To ensure appropriate treatment and monitor the patient's progress, several follow-up measures can be taken, including: • Schedule follow-up visits: The patient should be scheduled for follow-up visits with the physician to monitor his progress and response to treatment. The frequency of the visits may depend on the severity of the symptoms and the treatment plan. • Perform serial examinations: Serial examinations should be performed to assess for improvement in pain and range of motion. This can help the physician evaluate the effectiveness of the treatment plan and adjust it accordingly. • Repeat imaging studies: Imaging studies such as X-rays and MRI may be repeated to evaluate for changes in the spine that may be contributing to the pain. This can help the physician track the progress of the condition and determine if further interventions are necessary. • Encourage reporting of symptoms: The patient should be encouraged to report any new or worsening symptoms, such as increased pain or numbness or weakness in the legs, which may indicate nerve impingement. This can help the physician adjust the treatment plan or refer the patient for further evaluation if necessary. Overall, close monitoring of the patient's progress is essential to ensure appropriate treatment and prevent the development of any complications.