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NURSE 6531 CH wk 9 iHum.pdf 65-year-old Caucasian woman, presents to the office with the chief complaint of severe lower back pain. The pain began two days ago when she was rearranging a heavy tabl... e. SHe describes the pain as continuous and sharp, rating it a 7/10. Nothing alleviates the pain but worsens with movement which has since radiated to her right leg. The pt has not taken any medication for it. Due to the pain, she has difficulty walking, sleeping, and cannot work. Upon physical examination, the patient was found to exhibit hyporeflexia: right patellar tendon. Positive for right SLR and contralateral SLR. RLE sensory, motor, and reflex deficits. Patient is likewise unable to bend at waist without significant pain. The patient is diagnosed with HTN, asthma, and osteoporosis. Medical Hx includes TAHBSO. She has a 40-year history of smoking 1 pack of cigarettes a day and history of intermittent steroid use (for asthma exacerbation). Primary Diagnosis and ICD-10 code: -DISC HERNIATION (M51.26). A herniated disc is a common cause of back pain. It is a condition during which a nucleus pulposus is displaced from intervertebral space in the spine (Amin, Andrade, & Neuman, 2017). In the patient’s case, the onset of the pain, her history of osteoporosis, and reported symptoms, taken along with findings of positive straight leg raise (SLR) and positive contralateral SLR, all point to a herniated disc (Arts et al., 2019). DIfferential Diagnoses: -Due to presenting symptoms of back pain, differential diagnoses for this condition may include Osteomyelitis, spinal stenosis, Spinal Abscess, Rheumatoid arthritis, and Nephrolithiasis (Amin et al., 2017). The expert chose spinal neoplasm and compression fracture which agree also with the symptoms presented by the patient. Additional laboratory and diagnostic tests: -Because of the suspicion of disc herniation, an x-ray was requested since it is most inexpensive and could potentially show the problem-- this would also help rule out or confirm the differential diagnoses listed above. However, the best choice is Magnetic Resonance Imaging or MRI “which can show the spinal cord, nerve roots, and surrounding areas, as well as enlargement, degeneration, and tumors” as it makes a 3-D image (Amin et al., 2017; Kim et al., 2018). Consults: REFERRALS TO: -physiatrist for back pain management -orthopedic surgeon and neurosurgeon for possibility of surgery. According to Arts et al. (2019), surgery results in faster symptom relief than continued conservative care. -physical therapist Therapeutic modalities: -Take Tylenol (acetaminophen) 500mg now for pain relief - Tylenol 500mg PO every 4-6 hrs (can take as much as 1000mg per, 24- hour use < 4000mg) - Ice and heat therapy for pain relief - Patient needs to be seen by physiatrist now Health Promotion: • Daily low impact exercise, a balanced diet of mainly fruits and vegetables, and weight maintenance to address disc herniation, asthma, and hypertension. • Continue vitamin D and calcium supplementation for osteoporosis. • The patient will be strongly urged to stop smoking using nicotine patches and/ or CBT as it weakens the bones. • Continue annual checkups • Ensure immunizations are up to date • Bone density test (annually) and mammograms (every two years) Patient education: -The patient will be educated on disease process and how her personal factors affect the pathophysiology of the condition. She will also be educated on the appropriate use of Nonsteroidal Anti-inflammatory Drugs or NSAIDs. Even if the patient is not obese, she will be recommended to maintain weight control. -Patient must be advised correct positions when moving or lifting objects to avoid other similar episodes. -Advice on surgical treatment must be included. Discectomy which includes partial removal of the disc which causes symptoms is recommended as Amin et al. (2017) and Arts et al. (2019) find that pain is resolved faster with surgery rather than conservative options. Other options may include manipulation (such as chiropractic manipulation) under the advice of a surgeon. Narcotic pain medications may also be used for pain relief but must be avoided as much as possible. Disposition/follow-up instructions: - Patient to report after 24 hours regarding response to pain relief medications and nonpharma therapy (for added dosage, change in medication, etc) and visit to physiatrist, - Patient to see orthopedic surgeon in 48 hours whether or not pain has resolved. - Patient to inform clinic re: results of surgical consult. References Amin, R. M., Andrade, N. S., & Neuman, B. J. (2017). Lumbar Disc Herniation. Current reviews in musculoskeletal medicine, 10(4), 507–516. https://doi.org/ 10.1007/s12178-017-9441-4 Arts, M. P., Kuršumović, A., Miller, L. E., Wolfs, J., Perrin, J. M., Van de Kelft, E., & Heidecke, V. (2019). Comparison of treatments for lumbar disc herniation: Systematic review with network meta-analysis. Medicine, 98(7), e14410. https://doi.org/10.1097/MD.0000000000014410 icd10data.com (2020). Other intervertebral disc displacement, lumbar region. Retrieved from https://www.icd10data.com/ICD10CM/Codes/M00-M99/M50- M54/M51-/M51.26. Kim, J. H., van Rijn, R. M., van Tulder, M. W., Koes, B. W., de Boer, M. R., Ginai, A. Z., Ostelo, R., van der Windt, D., & Verhagen, A. P. (2018). Diagnostic accuracy of diagnostic imaging for lumbar disc herniation in adults with low back pain or sciatica is unknown; a systematic review. Chiropractic & manual therapies, 26, 37. https://doi.org/10.1186/s12998-018-0207-x [Show More]

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