Musculoskeletal Clinical Case

Week 5: Musculoskeletal Clinical Case

HPI

A 40-year-old Asian American male, who works as a roofer, complains that three days ago he was lifting a heavy object at work, following which he got low back pain. The pain is in the middle of the back near his waist. The pain increases when he bends forward and he is experiencing numbness and tingling in the toes of his right foot. He has had similar symptoms before, but it has not been so bad in the past. This is the worst he has had because in the earlier instances, he has never had the tingling sensation in his right foot before.

In the past, he got better with rest and some Ibuprofen. He is worried that he will not be able to continue his work and make money. He is out of work as a result of the pain. He has a lot of difficulty getting sleep at night. He has started taking some of his friend’s medication and it seems to help.

He has pain in the mid lumbar area, which radiates to the right buttock. He also has numbness and tingling down the back of his right thigh to his toes. The pain and numbness has been increasing since the problem started three days ago. He has tried over-the-counter Ibuprofen and some stretching exercises, but it does not seem to help. He has not sought any medical care yet. In the past, the pain had just gone away, but this time the pain is persistent. There is a gradual worsening of his symptoms and he is concerned about the pain that has been increasing steadily over the past three days. He is wondering whether he has a herniated disc. His major concern is that he has no health insurance and will be missing work.

PMH

He has had similar pain in the past, but it was not so severe. He saw a chiropractor around two or three years ago and that gave him some relief. Otherwise, the patient has no chronic medical problems. He does not seek medical care on a routine basis.

He has had no diagnostic measures in the past. He has never had any blood work reports, CT scan reports, X-ray reports and so forth done in the past. He has been gaining weight over the past few years and does not do any stretching exercises before work. Patient does not have any other risk factors. There are no records of any past surgeries. He has neither had any significant illnesses in the past nor any hospitalizations.

ROS

Pain in the mid lumbar area radiating to the right buttock. There is a tingling sensation that goes down the back of his right thigh to the toes. He does not have urinary or bowel incontinence. No nausea, vomiting, or fever. He denies abdominal pain and pain with urination. There is no gross hematuria.

MEDICATIONS

Patient does not take any prescription medications, only over-the-counter Ibuprofen. He is using 800mg of Ibuprofen every four hours. Patient is compliant with the prescribed regimen; in fact, he could be using too much. Patient is seeking care because of the increasing pain. He has tried chiropractic manipulations in the past for low back pain.

ALLERGIES/REACTIONS

He is allergic to Penicillin. It has caused a rash in the past.

SOCIAL HISTORY

This patient works for a local roofing company and makes $30,000.00 per year, which is just a little over the minimum wage. He has a high school education certificate and makes just enough money to get by. He has no health insurance. The patient feels that the last thing that he wants to do is spend money on healthcare. He feels his body will get better on its own, and so he can just keep working. He made the appointment at this outpatient clinic because his friends told him about it. He was not sure where to go for help. He has decreased access to healthcare because he is not aware of the services available. The patient has had essentially no healthcare to date. The patient states that he is starting to realize that his body will not last forever at his current position as a laborer.

The patient is divorced and thinks he was a failure as a husband. He is behind in alimony payments. His wife is alive and well without any medical problems. They do not communicate anymore. They have no children. He would like to try and get back together with her, but she refuses to speak to him. He has been holding himself back from expressing the amount of stress he has in life for many years. He thinks he is becoming depressed as a result of this. His parents still live in the area and he sees them every weekend. He has friends from work and they do social things together. The patient has not sought any emotional support from anybody. There is no element of family dysfunction. He becomes easily stressed out. He lives in social isolation from his community. The patient has always taken his health for granted and not thought much about it in the past.

HABITS

Smoking: Non smoker

Alcohol: Drinks at bars on weekends to excess with his friends

Substance abuse: He smokes marijuana.

DIET HABITS

He skips breakfast and eats at fast food restaurants twice every day. He sips coffee and caffeinated beverages throughout the day. The patient feels that his job gives him enough exercise and so he need not do anything else. He plans to go on a “diet” soon to lose the weight he has gained over the past few years, but is not sure about the diet he is going to follow.

WORK HABITS

The patient works as a roofer. He has had other labor-intensive jobs in the past that do not require an educational background. He does not enjoy his job. He knows it is a dead end job and wants to go to school. He is originally from United States and lives in a suburban community where resources are easily accessible, but he is not aware of them.

FAMILY HISTORY

Both parents have hypercholesterolemia. His 65-year-old father has prostate cancer. Both parents are being treated with medications for their high cholesterol levels. He has no siblings. There is a remote history of heart disease in his relatives.

PHYSICAL EXAMINATION

Vital Signs: Ht: 6’; Wt: 220; WC: 40; BP: 120/78; T: 97 po; P: 92 and regular; R: 18 non-labored

HEENT: WNL

Lymph Nodes: None

Lungs: Clear

Heart: RRR without murmur

Carotids: Not examined

Abdomen: Android obesity, otherwise benign

Rectum: Not examined

Genital/Pelvic: NA

Extremities, Including Pulses: 2+ pulses in the lower extremities

Neurologic:

Mental Status: Alert and oriented

Cranial Nerves: II – XII intact

Motor Strength: Upper extremities equal strength 5/5.

Lower extremities: decreased strength of right leg with resisted extension; patient complains of pain in posterior thigh.

Sensation (light touch, pin prick, vibration, and position): Decreased sensation of right leg along L5 : S 1 dermatome to pin prick stimulation compared with the left.

Reflexes: DTRs 2+ in upper and lower extremities

Cerebellar function intact—Romberg test is negative; heel-to-toe walking is steady.

Postive straight leg raise on the right at 20 degrees.

 

 

 

Comprehensive Plan of Care and Paper

Overview/Description:

You have been provided with case studies in Week 4 and Week 5 that focused on genitourinary and musculoskeletal disorders. You will pick one of these cases to analyze and create a comprehensive plan of care for acute/chronic care, disease prevention, and health promotion for that patient and disorder. Your care plan should be based on current best practices and supported with citations from current literature, such as systematic reviews, published practice guidelines, standards of care from specialty organizations, and other research based resources. In addition, you will provide a detailed scientific rationale that justifies the inclusion of this evidence in your plan. Your paper should adhere to APA format for title page, headings, citations, and references. The paper should be no more than 4 pages typed excluding title page and references.

Criteria:

• SOAP note
• Evaluation of priority diagnosis
• Facilitators and barriers to disorder management

Assignment 2 Grading Criteria	Maximum Points
Introduction The submission included a general introduction to the priority diagnosis.	10
Subjective Data The submission included the patient’s interpretation of current medical problem. It included chief complaint, history of present illness, current medications and reason prescribed, past medical history, family history, and review of systems.	15
Objective Data The submission included the measurements and observations obtained by the nurse practitioner. It included head to toe physical examination, laboratory and diagnostic testing results.	15
Assessment The submission included at least three priority diagnoses. Each diagnosis was supported by documentation in subjective and objective notes and free of essential omissions. All diagnoses were documented using acceptable terminologies and current ICD-10 codes.	20
Plan of Care Plan included diagnostic and therapeutic (pharmacologic and non-pharmacologic) management as well as education and counseling provided. The plan was supported by evidence/guidelines, and the follow-up plans were noted.	25
Evaluation of Priority Diagnosis The plan chose the priority diagnosis for the pt and differentiated the disorder from normal development. Discussed the physical and psychological demands the disorder places on the patient and family and key concepts to discuss with them. Identified key interdisciplinary team personnel needed and how this team will provide care to achieve optimal disorder management and outcomes.	25
Facilitators and Barriers The submission interpreted facilitators and barriers to optimal disorder management and outcomes and strategies to overcome the identified barriers.	20
Conclusion The submission included what should be taken away from this assignment.	10
APA/Style/Format The submission was free of grammatical, spelling, or punctuation errors. Citations and references were written in correct APA Style. Utilized proper format with coversheet, header.	10
Total	150

 

 

 

 

 

 

 

 

 

 

 

 

mprehensive Plan of Care and Paper ASSIGNMENT 2 Helpful Information

5 Pages Maximum (excluding title page and reference pages)

Assignment must include the following:

1. Introduction:
2. Discussion of the Priority Diagnosis with supporting evidence for the diagnosis.
3. Subjective Data:
4. Patient’s interpretation of current medical problem
5. Chief Complaint
6. History of present illness
7. Current medications and reason prescribed
8. Past medical history and family history,
9. Review of systems
10. Objective Data:
11. Measurements and observations obtained by the nurse practitioner
12. Head to toe physical examination
13. Laboratory and diagnostic testing results

4.     Assessment: a.     At least 3 priority diagnoses (Each diagnosis supported by documentation in subjective and objective notes and free of essential omissions). b.     Diagnoses documented using acceptable terminologies and current ICD-10 codes. 5.     Plan of Care: a.     Diagnostic and therapeutic (pharmacologic and non-pharmacologic) management b.     Patient education and counseling provided. c.     Evidence/guidelines, d.     Evidence-based follow-up plans 6.     Evaluation of Priority Diagnosis a.     Differentiated the disorder from normal development b.     Discussed the physical and psychological demands the disorder places on the patient and family c.     Discussed key concepts to discuss with patient and family. d.     Identified key interdisciplinary team personnel needed and how this team will provide care to achieve optimal disorder management and outcomes.
7.     Facilitators and Barriers Discussed a.     Evidence-based strategies to overcome identified barriers
You are welcome to combine items 2, 3 and 4 as noted above. But be sure to keep the other headings separated: Introduction, Plan of Care, Evaluation of Priority Diagnosis, and Facilitators and Barriers.