Week 5 reply

Case Study # 1: Susan, the Registered Nurse 

Demographics: 30YR Female 

Subjective: 

· Chief Complaint: Back pain due to work related injury. Inability to walk 

· HPI: A 30 year old female presents to the office after a work related injury stating “My back is killing me”. Patient is a registered nurse who attempted to prevent a patient from falling, resulting in twisting her back in the process. The pain has progressively gotten worse and now is complaining she can barely walk. 

· Onset: When did you first notice the back pain? 

· Location: Where is the pain located? Does the pain radiate anywhere else? 

· Duration: Have you experienced this problem before? What happened and was there any intervention performed? 

· Characteristics: Do you notice any other symptoms besides the back pain? 

· Aggravating: What makes the back worse? 

· Alleviating: Have you tried anything to relieve your symptoms? 

· Treatment: Have you taken any medications for the back pain recently and when was the last time you took it? 

· Severity: Do you notice your symptoms getting worse since it first started? Are these symptoms affecting other parts of your body or daily activity? Do you know if any of your family members are also prone to back pain or have conditions that put them at risk for back pain/fractures/etc? 

· Past Medical History: fractured coccyx, no sequelae 

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· “Any recent infection/illness?”

· Surgical History:  “Any recent surgeries or procedures?”

· Hospitalizations:  “Have you been hospitalized or gone to the ER/Urgent Care within the last 6 months- 1 year?” 

· Medications: 

· Depo Provera Birth Control injection q 13 weeks 

· OTC calcium- non compliant 

· “Have you ever taken corticosteroids for a long period of time and what for?” 

· Allergies:  NKA

· Immunization/Health Maintenance: 

· Depo Provera/Birth Control q 13 weeks injection

· Family History: 

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· Include mother and father’s past medical history. Specific on recurrent fractures, falls, osteoporosis, osteo-arithiris, rheumatoid arthritis.

· Social History: 

· Married with one child (5 years, female)

· Tobacco use: smokes half- pack of cigarettes since 15 years old, attempting to quit

· Occupation: Registered Nurse in transitional care 

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· “ Do you drink alcohol? How many glasses do you have a night/week?” 

· ROS: 

· General: Denies malaise, weakness, fevers or chills. Denies recent weight gain or losses of > 20lbs over the last 6 months. 

· Neurological: Denies numbness of the body part, weakness on one side of the body. Denies pins and needle sensation, abnormal movements. Denies neurological disorders

· Musculoskeletal: Reports muscle pain, back pain. Reports of recent accidents/injury. Reports physical disability and condition that limits activity and ADL’s 

Objective: 

· Vitals: No vitals presented but patients with pain may have elevated blood pressure, heart rate and respiratory rate. Pain scale is also important to determine with patients. Elevated temperature may reveal infection. 

· General: Vital signs stable, in no acute distress. Alert, well developed and well nourished 

· Musculoskeletal: Gait and station within normal limits. Limited ROM in lower extremities, diffuse tenderness, pain with flexion and lateral bending. 

Assessment: 

· Differential Diagnosis(s): 

· ICD- 10: M51.26: Other Intervertebral Disc Displacement 

· Disc degeneration is normally associated with disc herniation due to reduction in proteoglycans that leads to dehydration and disc collapse, increasing the strain on the annulus fibrosis resulting in tears and fissures (Qaraphli, 2023). When there are repetitive mechanical stresses applied to the disc, it can result in a gradual onset of symptoms leading to disc herniation. Lumbar disc herniation results from several changes in the intervertebral disc including; pressure exerted by the herniated disc on the longitudinal ligament and irritation caused by the local inflammation resulting in localized back pain (Qaraphli, 2023). Pertinent positives include; lower back pain and pain exacerbated by straining or walking. Pertinent negatives include; pain intensified in a seated position, pain exacerbated through coughing/sneezing and sensory abnormalities at the lumbosacral nerve root distribution. 

· ICD- 10: M48.00: Unspecified Site, Spinal Stenosis

· Spinal stenosis occurs when the spaces in the spine narrow and create pressure on the spinal cord and nerve roots (Raja, 2023). Depending on the position of the spine that was affected, each level of compression will produce different symptoms. Spinal stenosis is often caused by congenital or acquired etiologies with some congenital causes include; osteoporosis, apical vertebral wedging, thoracolumbar kyphosis, etc. Acquired stenosis primarily occurs from trauma and degenerative changes normally affecting the vertebral canal acutely with a mechanical force (Raja, 2023). Pertinent positives include; pain in the lower back and weakness in the legs and feet. Pertinent negatives include; burning sensation that radiates down the buttocks into the legs, numbness, tingling or cramping in the legs and feet and sometimes associated with neck pain or weakness in the upper extremities. 

· Working Diagnosis: 

· ICD- 10: M54.5: Low Back Pain

· Lower back pain (LBP) is not classified as a disease but more as a chief complaint many patients will have. LBP can be the result from occupation that requires hard labor and heavy exertion, those who view their occupation as repetitious or dissatisfying have been associated with a higher rate of LBP, obese/ sedentary lifestyle and poor posture (Dunphy, et. al, 2019). Force and stress applied to the spine is often the cause of injury and pain specifically looking at lumbar strains and sprains occurring together. LBP may also occur during motion if the stress is greater than the supporting structure can sustain or if the components of the lumbosacral spine are abnormal (Dunphy, et. al, 2019). Pertinent positives include; strain/sprain due to heavy lifting or twisting while carrying a heavy object, difficulty standing erect/walking and pain/tenderness. Pertinent negatives include; pain radiating to the buttocks, Waddell’s signs, and stiffness to the extremities. 

Plan: 

· Diagnostics: 

· Pregnancy test urinalysis/HcG prior to MRI/CT/X-ray

· MRI of the lumbar spine without contrast 

· CT of Spine 

· CBC with differential, C-reactive protein, and Erythrocyte Sedimentation Rate

· Straight- leg-raise test, Reverse straight- leg test or the prone rectus femoris test 

· Pharmacological: 

· NSAIDs- Ibuprofen 800 mg PO TID as needed 

· Neuropathic Pain- Gabapentin 300 mg PO TID

· Non-Pharmacological: 

· Acupuncture 

· Physical Therapy for rehabilitation 

· Patient Education: 

· Avoid bed rest if possible, no more than 1-2 days if needed

· Gradual introduce activities back as tolerated

· Heat application of heat and educate on modified sit ups/ low back stretches as apart of their daily routine 

· Cognitive behavioral therapy

· Gentle home exercise: yoga, tai chi

· Smoking cessation, diet/lifestyle change and compliance with medication

· Referrals: 

· Spinal Specialist consult for further evaluation and possible intervention if there are any red flag signs or symptoms, neurological deficit, intractable pain, trauma history or examination reveals instability or fracture

· Physical Therapy, Pain Management center 

· Smoking cessation 

· Health Maintenance: 

· Pap Smear q 5 years alongside HPV testing 

· Annual STI/HIV screening

· Birth Control injection q 13 weeks check up 

· Annual Physical q 6 months/1 year → CBC/CMP/Thyroid function/A1C/urinalysis/ Pregnancy test

· Diet/lifestyle changes→ smoking cessation 

· DEXA scan annual 

· Yearly vaccines/immunization

· RTC: 

· 2-3 week follow up to determine the healing process and if stronger pain medication is needed or if possible surgical intervention is needed. Determine if referral to pain management is needed and if physical therapy is improving symptoms. Update on smoking cessation and other dietary lifestyle changes. The patient should contact the office or go to the emergency department if symptoms persist, worsen or progress; significant pain persists beyond one week and if there is no improvement with home management. 

 

Reference: 

Dunphy, H. L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary care: The Art and Science of Advanced Practice Nursing (Sixth Edition). F.A. Davis Company.

Raja, A. (2023, June 12). Spinal Stenosis. StatPearls [Internet].  https://www.ncbi.nlm.nih.gov/books/NBK441989/

Qaraghli, M. I. A. (2023, August 23). Lumbar Disc Herniation. StatPearls [Internet].  https://www.ncbi.nlm.nih.gov/books/NBK560878/