Clinical Case Presentation - Adult II

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Musculoskeletal Case

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Clinical Case Presentation :

MUSCULOSKELETAL CASE NURS 623: Adult II Practicum Maryville university By: Ashley Raley Clinical Case Presentation

Chief Complaint:

Chief Complaint A 37 year old Caucasian male presented to the clinic with a chief complaint of lower back pain that started approximately 3 weeks ago.

History of Present Illness (HPI):

History of Present Illness (HPI) O nset - 3 weeks ago after playing a soccer game. D enies any recent injuries or history of spinal problems. Shortly thereafter , patient took long road trip and 3-4 days later, symptoms worsened – increased tightness and discomfort to left side of lower back with radiating pain. Seen 2 weeks ago at an Urgent care facility. Prescribed Vicoprofen, Flexeril, and celestone injection. This only provided temporary relief. R eceived chiropractic care and this only provided about 30 minutes of complete relief and then pain returned. P resented to clinic as lower back pain has progressively gotten worse. Patient describes the pain to his left lower back as throbbing and tight with radiating pain/numbness/tingling to left lower leg. Also reports intermittent numbness to only his left 4 th and 5 th metatarsal. Pain affects his ability to perform activities. Pain 8/10 and aggravated with sitting, driving, or increased activity. Pain 3-4/10 with relief from Vicoprofen, standing, and laying down.

Review of Systems (ROS):

Review of Systems (ROS) Constitutional: denies fever, chills, malaise. Eyes : W ears contact lenses, denies difficulty seeing or vision changes. Last eye exam in 2013. ENT : Denies nasal congestion or discharge, sore throat, earaches, nose bleeds. Cardiovascular: Denies chest pain, palpitations, or lower leg edema. Respiratory: Denies shortness of breath, wheezing, or cough. Gastrointestinal: Denies abdominal pain, nausea, vomiting , diarrhea, or blood in stool. Reports good appetite . Denies heartburn. Genitourinary: Denies loss of bladder control, hesitancy, decreased urine stream, dysuria , or hematuria. Musculoskeletal : Reports pain and tightness to left lower back, radiating pain to left lower extremity. Neurological: Reports numbness/tingling to left lower extremity, numbness to 4 th and 5 th left metatarsals, occasional leg spasms. Denies headache, dizziness , gait abnormalities, or syncopal events. Psychiatric : Denies anxiety, depression. Hematologic : Denies tendency for easy bleeding and bruising.

Past Medical & Surgical History :

Past Medical & Surgical History Medical History: No significant medical history Surgical History Inguinal hernia repair - 1999

Family & Social History:

Family & Social History Family History Maternal history of obesity, hypertension, and diabetes Sororal history of diabetes, obesity Father: deceased due to lung cancer, former smoker Social History Never smoker Drink alcohol – socially. Drinks beer, approximately 3-4 cans per week. Denies history or current use of recreational drugs Married. Denies multiple sex partners. Patient is an electrician and lives with wife and 2 daughters in safe home environment.

Allergies & Current Medications:

Allergies & Current Medications Allergies No known food or drug allergies Current Medications Vicoprofen 7.5-200mg 1 tablet PO every 8 hours as needed for pain Flexeril 10mg PO BID for muscle spasms

Physical Exam Findings:

Physical Exam Findings Vitals Blood pressure: 124/94 left arm; 128/92 right arm Pulse: 70 bpm Respirations: 16 breaths/minute Temperature: 98.2 O 2 Saturation: 97% RA Pain 6/10 H eight: 6’1 Weight 225lbs BMI: 29.7

Physical Exam Findings:

Physical Exam Findings Constitutional: healthy, well-nourished, cleanly groomed, Caucasian male, no apparent distress Skin: pink, warm, dry, skin turgor good, no rash or lesions present Eyes: PERRLA, extra ocular muscles intact, sclera white, no erythema to peri -orbital area, no drainage from conjunctiva noted. ENT : R ight and left TMs translucent. Inferior and middle turbinates pink and moist . No signs of nasal congestion. Good dentition, gingiva pink. Oropharynx pink, no cobblestoning, post-nasal drainage, or erythema noted. Tonsils 2+. Uvula midline, gag reflex intact. Neck: trachea midline , no cervical lymphadenopathy noted, full ROM, no thyroid enlargement , carotid pulses +2, negative bruit and thrill Cardiovascular : Regular rate and rhythm, - S1/S2 heard upon auscultation, no ectopy, murmurs , or rubs. Carotid pulses and S1 are synchronous. No JVD at 45 degrees. Peripheral pulses +2. Cap refill 2 seconds and nail beds are pink . No edema o bilateral lower extremities. Pulmonary : Lungs clear to auscultation . Respiratory rate 16 breaths per minute with no signs of accessory muscle use. Respiratory effort is normal. No cough. Chest expansion symmetric with inspiration. Abdomen : Flat, non-distended, soft, and non-tender. No abdominal pulsations or bruits, bowel sounds active in all four quadrants , tympany percussed in all four quadrants Lymphatic : No lymphadenopathy noted. Musculoskeletal : Inspection: normal curvature of the spine. Negative CVA and sacroiliac joint tenderness, no vertebral spine tenderness with palpation. Full ROM to upper/lower extremities, increased pain elicited to left lower leg with straight leg lif t , adequate sensation and circulation to LLE, no swelling, bruising, or signs of acute injury to lower back or LLE. Neurologic: Alert and oriented x 3. CN 2-12 grossly intact . Motor strength normal to upper and lower extremities. Deep tendon reflexes intact . Sensory intact, however, intermittent numbness/tingling to LLE. Psychiatric : calm, pleasant affect.

Diagnostic Test Findings:

Diagnostic Test Findings Ordered by RediMed Urgent Care approximately 2 weeks ago X-ray of lumbar spine – AP and lateral views completed by RediMed Urgent Care Findings – There is no evidence of fracture or dislocation. There is moderate diffuse hypertrophic spurring anterolaterally. Bone density is normal. The pedicles are intact. Alignment is fairly anatomic. Impression: moderate degenerative changes. Ordered in clinic MRI of lumbar spine with no contrast ordered in office Findings –There is moderate disc space narrowing at L5-S1. The vertebral body heights are preserved. There is mild central canal narrowing and moderate left neuroforminal narrowing seen. Degenerative changes at L5-S1. At L5-S1 there is also a large disc extrusion causing central canal and left lateral recess narrowing.

Differential Diagnoses:

Differential Diagnoses Differential Diagnoses Herniated Lumbar Disc Sciatica Muscle Strain

Assessment Overview:

Assessment Overview Assessment Overview: Acute onset of lower back pain x 3 weeks, denies injury or trauma Complains of lower back pain radiating down left leg causing intermittent numbness and tingling. Aggravating factors – sitting and driving. Alleviating factor – standing and lying. Temporary relief with taking medications prescribed and chiropractic care. Numbness and tingling more prominent to 4 th and 5 th left metatarsals Negative Sacroiliac joint tenderness Full ROM to left leg, however, increased pain elicited with straight leg lift Diagnosis: H erniated Lumbar Disc at L5-S1 causing sciatica MRI Results confirm - L5-S1 disc herniation migrating inferiorly and impinging S1 nerve on the left It is Important to note these findings are consistent with the patient’s pain syndrome and clinical exam.

Anatomy & Dermatomes:

Anatomy & Dermatomes

Plan:

Plan Conservative Therapy x 3-6 months This would include referral to physical therapy Patient may continue chiropractic care Continue analgesics including Vicoprofen 7.5-200mg 1 tablet PO every 8 hours as needed for pain and Flexeril 10mg PO BID for muscle spasms. Will prescribe Medrol Dose pack to help alleviate inflammation at lumbar site. Encourage rest to help calm pain, avoid contact sports, and strenuous activity. Refer to Orthopedist Recommend consultation based on MRI findings Inquire about epidural steroid injections to lumbar spine In some cases a microdiskectomy may be recommended to resolve disc herniation What are the risks and benefits? Do benefits of surgical intervention outweigh conservative measures?

Key Points:

Key Points History of present illness and clinical findings should match. If symptoms and clinical findings do not match = consider the patient may be drug seeking It is important to assess neurological symptoms – Although rare, loss of bladder or bowel control is a danger sign, indicative of severe spinal nerve root compression and would require immediate medical attention (AAOS, 2012). In addition, asking the patient if they have experienced fever, night sweats, or weight loss, associated with lower back pain, could signify possible infection or cancer, such as meningitis or prostate cancer. Key Assessment on Physical Exam – Straight leg raise – An accurate predictor of disc herniation for patients under age 35. It is thought that those younger than 35 should have minimal arthritic changes and be able to perform test with minimal limitation. To perform test, the patient is asked to lie supine and the practitioner would then lift the affected leg with the knee staying straight. If the patient experiences pain down their leg or below the knee, this is a considered a positive test for disc herniation (AAOS, 2012). Assess risk factors for disc herniation – Male, heaving lifting, repetitive activities that cause increased back strain, frequent driving, sedentary lifestyle, and smoking (AAOS, 2012).

PowerPoint Presentation:

I hope you learned something to help you in your future clinical endeavors! Thank you for watching! – Ashley Raley

References:

References American Academy of Orthopaedic Surgeons. (2012). Retrieved from http :// orthoinfo.aaos.org/topic.cfm?topic=a00534 Dartmouth Hitchcock. (2013). Research at the spine c enter : spine p atient o utcomes r esearch trial. Retrieved from http :// www.youtube.com/watch?v=pLLQU4OSeLQ

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