Discuss the Mr. Payne’s history that would be pertinent to his genitourinary problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
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Mr. Payne is a 45-year-old male truck driver that presents with a two-week history of low back pain that radiates down his left leg to his ankle that started after lifting a box while at work. He does have a history of back pain that he states usually goes away within 2-3 days of onset. He states “this is the worst pain I have ever had. He describes the pain as sharp, stabbing and rates it a 7 out of 10 on the pain scale when at its worst. Initially he used ice and took Ibuprofen 400 mg every 6 hours for three days and then tried Naproxen 250 mg once daily for five days. He states that this initial treatment worked, but then he played softball with his daughter and pain returned and has become more constant and not relieved by medication. Pain is aggravated by any movement and sitting for long periods of time. He states that lying down relieves his pain. His job requires him to sit for long periods of time and requires lifting 20-35 pounds 4 hours a day. He has a 20-pack year smoking history but quit 2 years ago. He reports no IV or recreational drug use but does drink a “couple of beers” every now and then on the weekend. He has a history of diabetes, HTN and hyperlipidemia. Current medications include Metformin 1000mg PO twice daily and Glyburide 10mg PO twice daily for diabetes, Amlodipine 2.5 mg PO daily and Lisinopril 40 mg PO daily for HTN, and Simvastatin 40 mg PO daily for hyperlipidemia. He reports no drug allergies. He denies any numbness or weakness in legs, urinary frequency, dysuria, problems with bowel or bladder control, fever or chills, nausea or vomiting, night pain, recent trauma, or weight loss.
Describe the physical exam and diagnostic tools to be used for Mr. Payne. Are there any additional you would have liked to be included that were not?
The physical exam of Mr. Payne included a detailed history of his pain, vital signs, auscultation of the abdomen to assess for bruit (which could indicate an abdominal aortic aneurysm), palpation of the abdomen to check for any masses or tenderness. A standing sitting and supine back exams were also performed. During the standing exam, the patient was observed for any abnormalities in gait, posture, contour, and symmetry of the back. Range of motion and palpation for tenderness were performed. The V. scoop test was also performed. This is where the patient squats from the standing position (this will relieve pain with spinal stenosis). The sitting exam assessed deep tendon reflexes, muscle strength, and sensation of lower extremities. The Supine back exam included abdomen exam, straight leg test, and FABER test to which only the straight leg raise elicited a positive response. At this time, it has only been 2 weeks since the pain has started and there are no red flags that would indicate any further testing such as fever, loss of bladder control, pain that wakes him up at night, or weight loss.
Please list 3 differential diagnoses for Mr. Payne and explain why you chose them. What was your final diagnosis and how did you make the determination?
The three differential diagnoses that I initially went with were lumbar strain, Herniated disk, and degenerative arthritis. According to the differential for low back pain section in the case study, the symptoms of these three diagnoses are very similar and can manifest as pain in the lower back with potential to radiate down the leg. I chose my final diagnosis of herniated disk due to his reported history and the findings during the physical exam. According to The Mayo Clinic (2019) a herniated disk is when the jell like center of the spinal disk leaks out through a tear in the tougher exterior containing it. This irritates the nerves in the spinal canal causing pain. “The most common cause of radicular pain to the lower extremities is a herniated lumbar intervertebral disc” (Dunphy, Winland-Brown, Porter & Thomas, 2019, p. 824). The findings of a positive straight leg raise on the left and negative on the right, tenderness of the left paraspinous muscle, acute onset while lifting, pain that gets worse while sitting and relieved by laying down, and his history of previous back pain and occupation as a truck driver are all indicative of herniated disk according to the case study.
What plan of care will Mr. Payne be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
The plan of care for this initial visit is to put the patient on conservative care since he has only had pain for two weeks. According to the case study, this includes aspirin, NSAIDs and/or muscle relaxers, local heat/cold therapy, and physical therapy. The patient was given a referral to physical therapy and instructed to increase his dosage of Naproxen to 500 mg orally BID. He was also prescribed acetaminophen with codeine. According to drugs.com (2020) the dose should be the least amount to be effective, so 300mg/15mg orally every 4 hours for pain will be the initial dose prescribed. He will only be given a 7-day supply to minimize chances of dependence. Patient education would include reassurance that most cases of acute low back pain resolve within 6 weeks. I would also instruct the patient that he is to take naproxen with food and to take the acetaminophen with codeine at night and with severe pain. He will be instructed to avoid taking any other OTC medications with Tylenol in them and to make sure that he does not exceed 4000 mg of acetaminophen within a 24-hour period. Patient will be instructed to call office immediately if he starts to experience any loss of bladder/ bowel control, develops a fever or severe pain that wakens him at night, or experiences muscle weakness. For his job, I would do education on proper lift technique and posture to help avoid future injuries.
With the follow up visit, the patient states that treatment is not helping, and pain is getting worse. It has now been over a month and further treatment is need. MRI is ordered to confirm diagnosis. The MRI dose confirm diagnosis and patient is given the option to be referred to a surgeon to discuss a surgical intervention or a referral to an osteopathic physician for osteopathic manipulation. The patient states that he would like to avoid surgery and is referred to an osteopathic physician. This treatment is effective for the patient and he is also put on a walking program to help with weight loss and increased activity.
Acetaminophen / codeine dosage. (2020). https://www.drugs.com/dosage/
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019).
Primary care: The art and science of advanced practice nursing-An
interprofessional approach (5th ed.). F.A. Davis Company.
Herniated disk. (2019). https://www.mayoclinic.org/diseases-conditions/herniated-
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