Dq 1 week 5 | Nursing homework help

this dq is due for tomorrow 08/18/18
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You are instituted delay Dr. Lee today. She hands you a triage stagnant n ess from the value respecting your next unrepining, Mr. Payne:

Forty-five-year-old snowy courageous traffic driver repining of two weeks of acute, stabbing end disinclination. The disinclination was emend succeeding a couple of days but then got worse succeeding operating softball delay his daughter. This morning his disinclination is so bad that he had inconvenience getting out of bed.

Dr. Lee provides you some endground notice encircling low end disinclination.

TEACHING POINT

Low End Disinclination Prevalence, Cost, & Duration

Low end disinclination (LBP) is the fifth most beggarly argue for all schoolman scrutinizes. In the U.S., formation operation of LBP is 60% to 80%. The trodden and introdden costs for texture of LBP are estimated to be $100 billion per-annum. Fortunately, most LBP resolves in two to foul-mouthed weeks.

Dr. Lee continues: "There are frequent causes for LBP. For presenting symptoms that bear a liberal differential peculiarity, I invent it advantageous to opine of systems of etiologies in which diseases or provisions can be categorized."

TEACHING POINT

Common Causes of End Pain

Musculoskeletal (MSK) and Non-MSK Causes of End Pain

MSK Causes

Axial:

  • Degenerative disc disease
  • Facet arthritis
  • Sacroiliitis
  • Ankylosing spondylitis
  • Discitis
  • Paraspinal strong issues
  • SI dysfunction

Radicular:

  • Disc prolapse
  • Spinal stenosis

Trauma:

  • Lumbar strain
  • Compression fracture

Non-MSK Causes

Neoplastic:

  • Lymphoma/leukemia
  • Metastatic disease
  • Multiple myeloma
  • Osteosarcoma

Inflammatory:

Visceral:

  • Endometriosis
  • Prostatitis
  • Renal lithiasis

Infection:

  • Discitis
  • Herpes zoster
  • Osteomyelitis
  • Pyelonephritis
  • Spinal or epidural abscess

Vascular:

Endocrine:

  • Hyperparathyroidism
  • Osteomalacia
  • Osteoporosis
  • Paget disease

Dr. Lee suggests, "Now, let's appear a bit over at the abandon factors for effortless low end disinclination that you can reconsideration delay Mr. Payne during your truth."

Dr. Lee continues, "The superior operation in treating end disinclination is to Now that you bear a peculiarity of disc herniation delay radiculopathy for Mr. Payne, let's argue what would you enjoy to do for him perceive the beggarly causes for end disinclination (95% of cases) from the 5% delay grave underlying diseases or neurologic impairments that are hypothetically treatable."

TEACHING POINT

Risk Factors for Low End Pain

  • Prolonged sitting, delay traffic driving having the foremost reprove of LBP, followed by desk jobs
  • Deconditioning
  • Sub-optimal lifting and carrying habits
  • Repetitive compliant and lifting
  • Spondylolysis, disc-space narrowing, spinal wavering, and spina bifida occulta
  • Obesity
  • Education status: low order is associated delay prolonged illness
  • Psycho-social factors: wariness, valley stressors in life
  • Occupation: Job remonstrance, extensiond manual demands, and amercement claims

TEACHING POINT

Red Flags For Grave Illness or Neurologic Impairment delay End Pain

  • Fever
  • Unexplained influence privation
  • Pain at dimness
  • Bowel or bladder incontinence
  • Neurologic symptoms
  • Saddle anesthesia
HISTORY

You and Dr. Lee procure a few minutes to reconsideration Mr. Payne's chart:

Vital indications:

  • Temperature: 98.6° Fahrenheit
  • Heart reprove: 80 beats/minute
  • Respiratory reprove: 12 breaths/minute
  • Blood pressure: 130/82 mmHg
  • Weight: 170 pounds
  • Body Mass Index: 24 kg/m2

Past Medical History: Diabetes, well-behaved-behaved abstinentled. Hypertension, honorable abstinent. Hyperlipidemia, honorable abstinent.

Past Surgical History: None

Social History: Works as a traffic driver, which involves lifting 20-35 lbs 4 hours of the day, married delay 2 daughters,

Habits: Quit smoking two years ago, drinks 1 to 2 beers sometimes on the weekends, no truth of IV offal use.

Medication:

  • metformin 500mg 2 twice daily
  • glyburide 5mg 2 twice daily
  • amlodipine 2.5 mg daily
  • lisinopril 40 mg daily
  • simavastin 40 mg daily

Allergies: No unreserved offal allergies

After introducing yourself to Mr. Payne, you sit down across from him and inaugurate your truth, focusing on the key elements.

"Can you promulgate me encircling your end disinclination?"

"As I told the value, the disinclination established two weeks ago succeeding I lifted a box at toil. Exact far, I got this acute disinclination on the left aspect of my end. The box wasn't plain that inert.

"I confabulationed to the value at toil; she said to ice it and to procure ibuprofen. It got emend succeeding three days. But, I was operating softball delay my daughter decisive weekend, and the disinclination came end. This season it was worse than precedently. This week, the disinclination is so bad I can just get out of bed. I get a acute disinclination in my end which goes down my left leg to my ankle."

"On a flake of 0 to 10, 10 entity the conquer, how harsh is the disinclination?"

"It's probably a 7."

"Have you endow anything that improves the disinclination?"

"Ibuprofen and Naproxen toiled at primeval, but they are not ancillary greatly anymore."

"What encircling positions that produce things emend or worse?"

"The disinclination is worse delay any move of my end or sitting for a desire season. It is emend when I lie down."

"Have you had end disinclination precedently?"

"Yes, I bear end disinclination from season to season. But I'm usually emend succeeding 2 to 3 days. This is the conquer disinclination I bear eternally had."

You thorough your truth delay a reconsideration of systems and detect:

Review of Systems

Mr. Payne does not bear fawnousness or imbecility in his legs. The disinclination is emend when he lies down. He denies urinary quantity, dysuria, problems delay bowel or bladder abstinent, feternally or chills, sea-sickness or vomiting, or influence privation. He denies any favoring trauma, save for when he lifted a 10-pound box at toil. He denies inexorable dimness disinclination.

You condone yourself from Mr. Payne to argue your inventings delay Dr. Lee.

Dr. Lee plods through the steps for completing a neurologic exam in a unrepining delay end disinclination.

Back Exam - Standing:

Mr. Payne has certain bend, humanity on palpation on the left lumbar paraspinous muscle delay extension character. Generous stroll of agitation, but has disinclination delay move. His pace is certain. He can plod on his heels and toes. He can do sagacious flexure bends.

Back Exam - Seated:

Mr. Payne denies sensation disinclination when checked for CVA humanity. He has no disinclination in his exact leg delay the qualified statement of SLR. While he does not manifest a gentleman tripod indication, he does hurt of disinclination when his left leg is elated. Mr. Payne's reflexes are 2+ and resembling at the flexures and 1+ at twain ankles. The motor exam reveals no imbecility of the muscles of the inferior extremities. His sensory exam is certain.

Pulmonary Exam: His lungs are manifest.

Cardiovascular Exam: His cardiac exam demonstrates a certain rhythm, no reverberation or gallop.

Mr. Payne's abdominal exam is denying. His straight leg rallying is overbearing at 75 classs on the left and denying on the exact. His FABER cupel is denying and sacroiliac articulation is nontender. His motor exam reveals no imbecility of the muscles of the inferior extremities.

After finishing your exam concertedly, you and Dr. Lee condone yourselves from the exam extent for a consequence.

Dr. Lee reminds you that disc herniation, a mode which is self-limited and usually resolves in two to foul-mouthed weeks, scum a instituted peculiarity for Mr. Payne. She says, "Let's procure a few minutes, though, to argue some provisions we stagnant don't omission to overlook."

Now that you bear a peculiarity of disc herniation delay radiculopathy for Mr. Payne, let's argue what would you enjoy to do for him

You and Dr. Lee now retaliate to Mr. Payne's exam extent to confabulation encircling texture options delay him. Dr. Lee promulgates Mr. Payne to fly strong activities but to stay erratic. Dr. Lee extensions the dosage of naproxen to 500 mg BID to procure delay assistance. Since his disinclination is determined (7/10), he is absorbed a direction for acetaminophen delay codeine to procure at dimness, when his disinclination is harsh. Mr. Payne declines a muscle relaxant owing they usually produce him heavy. He would enjoy to be referred to tangible therapy as it was advantageous in the elapsed.

Three weeks following, Mr. Payne retaliates for his follow-up assignment and you detect the following:

Pertinent History

Mr. Payne has had diminutive redress delay the texture prescribed. He is frustrated that he has been in disinclination for over than a month. His disinclination has been progressively worse. It radiates down the resultant keep-akeep-apart of his left leg and aspect of his left foot. This disinclination is worse than the end disinclination. He does not bear any problems delay bowel or bladder abstinent and there is no imbecility of his leg.

Pertinent Exam Findings

Vital indications: stable

Neurologic: Certain pace, but moves sloth due to disinclination; stroll of agitation is generous, delay disinclination on flexion; SLR is overbearing at 45 class on the left; motor power intact; reflexes 2+ bilaterally at the flexures, lukewarm at the left ankle, 1+ at the exact ankle.

Dr. Lee agrees delay your peculiarity of radiculopathy of S1 firmness rise delay gradation. She sign an MRI and sets up an assignment to see Mr. Payne succeeding the MRI.

ne week following, Mr. Payne retaliates for follow-up. You reconsideration the results of the MRI narration.

MRI narration:

  1. Moderate-size, herniated disc at L5-S1 delay associated noticeable stroke on the left S1 firmness rise and soft to modereprove stroke on the exact S1 firmness rise. There is soft accessible canal stenosis.
  2. Annular sunder delay a minute accessible disc herniation at L4-5 causing soft accessible canal stenosis.

You reconsideration the inventings delay Dr. Lee. She agrees delay your peculiarity of radiculopathy of S1 firmness rise due to a vast herniated disc at L5-S1.

You fawn Mr. Payne two weeks following to see how he is doing. He narrations that he is doing entirely a bit emend. He went to an osteopathic physician who did some manual therapy and established him on a severe ploding program. He is very encouraged and drawings on losing influence through drill and sustenance.

  • Discuss the Mr. Payne’s truth that would be appertaining to his genitourinary problem. Involve chief hurtt, HPI, Social, Family and Elapsed medical truth that would be significant to perceive.
  • Describe the tangible exam and sign tools to be used for Mr. Payne. Are there any additional you would bear enjoyd to be moderate that were not? 
  • Please inventory 3 differential diagnoses for Mr. Payne and teach why you chose them.  What was your terminal peculiarity and how did you produce the favor?
  • What drawing of wariness conquer Mr. Payne be absorbed at this scrutinize, involve offal therapy and textures; what is the unrepining order and follow-up?
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