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Case 1:Back Pain. A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
- Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
- Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient\'s differential diagnosis, and justify why you selected each.
- Consider what history would be necessary to collect from the patient in the case study you were assigned.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\'s condition. How would the results be used to make a diagnosis?
- Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
****please use below template
Episodic/Focused SOAP Note Template
Initials, Age, Sex, Race
CC (chief complaint) a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance \"headache\", NOT \"bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here - such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.
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Patient Initials: Mr. X
Age: 42 years
Race/Ethnicity: African American.
CC: “Pain in my lower back for the past one month. The pain sometimes radiates to my left leg.”
HPI: The patient is a 42 years African American male presenting with dull lower back pain for the last one month. The pain started after he worked in his garden. It radiates to his left leg after prolonged sitting and it has significantly affected his productivity at work. He rates the pain as an 8/10 and he has taken paracetamol 1000mg twice daily for the past two weeks. Although it provides some pain relief, the pain persists thereafter.
Current Medications: Nifedipine 20 mg PO daily, Lipitor 20 mg PO daily.
Allergies: He has no known food or drug allergies.
PMHx: He was diagnosed with hypertension ten years ago and is on medication for hyperlipidemia. His immunization status is up to date- TDap 2014 and Influenza October 1, 2016.
Soc Hx: He smokes a maximum of 6 cigarettes a day and denies alcohol or any illicit drug use. He is a staunch catholic who attends services every Sunday. He does not exercise regularly.
Fam Hx: His mother died three years ago from diabetic complications. His father is hypertensive and has currently been diagnosed with diabetes at 75 years old. He also suffers from osteoarthritis.
General: The patient denies lack of energy, fevers, chills, night sweats, and weight changes.
Skin: Denies persistent rash, itching, new skin lesion, hair loss, or increase.
HEENT: Denies difficulty with hearing, sinus pain/pressure, congestion, runny nose, post-nasal drip, ringing in ears, difficulty swallowing, mouth sores, loose teeth, ear pain, nosebleeds, sore throat, facial pain or numbness, neck pain/stiffness.
Cardiovascular: Denies chest pain, irregular or rapid heartbeat.
Respiratory: Denies shortness of breath, cough, wheezing, or sputum production.
GI: Denies heartburn, constipation, nausea, vomiting, diarrhea, abdominal pain, difficulty swallowing, blood in stools, unexplained change in bowel habits, or incontinence.
GU: Denies painful urination, frequent urination, urgency, urine retention, changes in penial discharge, impotence.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
Musculoskeletal: Denies joint pains, muscle pain/tenderness, neck pain, thigh or calf cramps.
Neurologic: Denies frequent headaches, double vision, weakness, decreased sensation to extremities, denies numbness or tingling of extremities, denies numbness, or tingling of extremities, imbalance, unsteady gait, dizziness, tremor, loss of consciousness, uncontrolled motions, episodes of visual loss, bowel or bladder incontinence.
Psychiatric: Denies insomnia, depression, recurrent bad thoughts, mood swings, hallucinations, compulsions.
Endocrine: Denies intolerance to heat or cold, menstrual irregularities, frequent hunger/urination/thirst.
Hematological: Denies bleeding tendencies such as nose bleeds or gum bleeding, easy bruising.
Vital Signs: Bp: 140/70, HR: 80 beats/min, 20 RR, HT: 5’5’’, WT: 176.37 lbs.
The patient has no back tenderness, positive Lasegue sign (straight leg test), absent ankle reflex, unremarkable strength, and sensation, intact bilateral hip motion.
Magnetic resonance imaging is the most accurate assessment for the lumbar spine area (Wassenaar et al., 2012). It reveals the exact position for herniation and the affected nerves. The patient's result reveals a lumbar herniation at the level of L5-S1. An Electromyography confirms the compression of the sciatic nerve secondary to the herniation. However, there is no evidence for any arthritic condition impact on the nerves.
A herniated lumbar disk is the most probable diagnosis for the patient. It is also referred to as a slipped or ruptured disc that can occur anywhere along the spine but it is common on the lower back or neck (Amin et al., 2017). Spinal discs separate each vertebra as a protective mechanism from shock. They are also responsible for movements like twisting and bending. Their absence would mean that the discs will grind on each other since there is no protection from trauma or body weight. Pain occurs when the outer part of the outer disc presses against the nerves that run along the spinal column and could explain the patient's lower back pain. The pain started after working in the garden. It is a strenuous physical activity suspicious for traumatizing the patient’s lumbar disks. Moreover, he is overweight with a BMI of 29.3 which increases his possibility for a herniated disc. Nicotine is also responsible for intervertebral disc generation through cell damage in the annulus and nucleus (Amin et al., 2017). The patient is a smoker, a habit that increases his risk for lumbar disc complications.
Sciatica is a differential diagnosis for the patient. The sciatic nerve originates from the spinal column and runs through the hips and buttocks before branching down to every leg (Mayo Clinic, 2020). It is a possibility because the patient’s pain originates from the back and radiates to his left leg. A possible explanation is that a herniated disc impinges on the nerves at the level of L5-S1. Evidence shows that nerve impingement is aggravated by actions like coughing, sneezing, or prolonged sitting (Mayo Clinic, 2020). It is consistent with the patient’s aggravated symptoms with prolonged sitting and a positive straight leg test where pain spread down his leg. The dull pain is also consistent with nerve impingement or radiculopathy.
Spinal stenosis is a possible diagnosis for the patient. It is a narrowing of the spinal canal in the lower part of the spine resulting in pressure on the spinal cord or the nerves that go from the spine to the muscles (Genevay & Atlas, 2010). Although it can occur at any part of the spine, it is common at the lower part- the lumbar vertebrae. Common causes include injury to the spine, bone diseases, and rheumatoid arthritis (Genevay & Atlas, 2010). The patient is experiencing lower back pain which makes it a possible diagnosis. Evidence shows that RA follows a genetic cause due to variations in the human leukocyte antigen HLA- DRB1 gene (Genevay & Atlas, 2010). The past family history of rheumatoid arthritis (RA) is a possible explanation for the possibility of spinal stenosis for the patient. Moreover, the beginning of the symptoms after working in the garden also rises suspicion of spinal injury.
Amin, R. M., Andrade, N. S., & Neuman, B. J. (2017). Lumbar disc herniation. Current reviews in musculoskeletal medicine, 10(4), 507-516. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685963/
Genevay, S., & Atlas, S. J. (2010). Lumbar spinal stenosis. Best practice & research Clinical rheumatology, 24(2), 253-265. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841052/
Mayo Clinic. (2020, August 1). Sciatica - Symptoms, and causes. https://www.mayoclinic.org/diseases-conditions/sciatica/symptoms-causes/syc-20377435
Wassenaar, M., van Rijn, R. M., van Tulder, M. W., Verhagen, A. P., van der Windt, D. A., Koes, B. W., & Ostelo, R. W. (2012). Magnetic resonance imaging for diagnosing lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. European spine journal, 21(2), 220-227.
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