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Peer 2

Chief Compliant: 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.

History of Present Illness: Lifted a box that was approximately 10lbs and experienced a pain that has occurred for about 2 weeks. Pain is about a 7. Pain is bad when he moves but does not bother him when he is laying down.

PMH: Diabetes, well-controlled. Hypertension, fair controlled. Hyperlipidemia, fair control.

Medication History: 

· 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

 

Allergy: No known drug allergies     

Surgical History: None

Social History: Works as a truck driver, which involves lifting 9-16 kgs (20-35lbs) 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.

Review of Symptoms: Pain is present when moving and has not been resolved with Ibuprofen or Naproxen. 

 

Objective Data:

Vital Signs: BP 130/82, HR 80, RR 12, T 98.6 F, Wt 170lbs, BMI 24 kg/m

Physical Assessment Findings: 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.

Laboratory and Diagnostic Test Results:

 

Assessment: 

The top 3 diagnosis that I came up with after reviewing the patients’ symptoms included degenerative arthritis, lumbar strain, and disc herniation. The final diagnosis was that of disc herniation which will consist of a few different therapeutic options and plans of care prior to his follow up. 

Plan of Care: The patient’s first action will be to ensure he minimizes over endurance but can have light activity. Overexerting himself could lead to other extensive issues with his back. Increasing his dosage of Naproxen will aid in reducing the amount of pain. Physical therapy will be recommended for different exercises understanding he is a truck driver. The constant sitting and lifting will put strain on his muscles; thus it is recommended that he follows up with his doctor within 3-4 weeks.