Musculoskeletal Case Study
The purpose of this discussion is to analyze critically a case study of a 40-year-old Asian-American man with a priority diagnosis of a lower back pain possibly due to a herniated disc. The backache diagnosis is the highest priority in this case scenario given the nature of the patient’s clinical manifestations and objective data obtained during the patient’s assessment. For instance, the patient complains of a lower back pain that radiates to the right leg, which is also numb. With such a manifestation, it is beyond doubt that this patient is a real candidate for a lower backache diagnosis. Thus, the analysis will entail relevant patient’s subjective, objective and assessment data. Additionally, it will include a plan of care, evaluation of the priority diagnosis and facilitator and barriers to the effective management of this condition.
Subjective, Objective Data and Assessment
Subjective Data
The patient’s impression of the current medical problem is that he is suffering from a lower backache due to a herniated disc. He comes in with a chief complaint of a lower backache and numbness of the right foot.
The history of presenting illness is that the pain has lasted for 3/7. The nature of the chief complaint is that it is persistent, severe, located in mid-lumbar pain and radiates to the right buttock and foot. Also, not relieved by rest or ibuprofen but with relieved with a friend’s medication.
Currently, the patient is not any prescribed medications but is on over-the-counter Ibuprofen 800mg four hourly. He is using the medication to relieve the back pain.
In the past medical history, this patient reports to have had similar pain but was not severe as the current one and was relieved by a chiropractor. He does not have any chronic condition and seeks medical care rarely. He has no history of diagnostic tests, hospitalization, or surgeries.
His family history suggests that he is a risk for hypercholesterolemia since his parents are both under treatment for the condition. Furthermore, he has a small probability of having a heart disease given the remote history of the condition within the family.
Lastly, under the review of systems, the patient’s musculoskeletal and neurovascular are the most affected given that he reports having pain in the mid-lumbar area that radiates to the right buttock and a tingling sensation that runs downs the right thigh to the toes. However, he denies the involvement of other body systems.
Objective Data
Vital Signs: Height: 6′; Weight: 220; Waist Circumference: 40; Blood Pressure: 120/78; Temperature: 97 PO; Pulse: 92 and regular; Respiratory: 18 non-labored
On physical examination, the significant findings include android obesity on abdominal assessment. The upper extremities have equal motor strength (5/5) while in the lower extremities, there is decreased the strength of right leg with resisted extension and pain is evident in posterior thigh. On assessing for sensation, the patient has a decreased sensation of the right foot along lumbar 5 to Sacral 1 dermatome to pinprick stimulation compared with the left. The deep tendon reflex is at 2+ in both upper and lower extremities. Lastly, the patient has an intact cerebellar function and a positive leg raise at 20 degrees.
Assessment
The three possible diagnoses for this patient include but not limited to the following:
- Lower back pain (M54.5) as evidenced by patient’s complaints and physical examination of pain in the mid lumbar region
- Overweight (E66.3) as evidenced by android obesity on abdominal examination, borderline waist circumference 40 (normal for males is below 40) and a BMI of 29.80
- Hypercholesterolemia (E78.00) as evidenced by the risk of familial inheritance, poor feeding habits (eating fast foods twice a day) and presence of android obesity on abdominal examination (Centers for Medicare & Medicaid Services, 2016)
Plan of Care
Low Back Pain
Diagnosis of this condition is possible through plain radiographs of the lumbar spine, radionuclide bone scintigraphy, computed tomography scan, and MRI. Additionally, laboratory testing such as erythrocyte sedimentation rate and C-reactive protein are also essential in quantifying the inflammation (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
Pharmacologic management is also critical in the recovery of the patient. It should begin with the use of acetaminophen and NSAIDs such as Aspirin. If the not useful in pain reduction, opioid analgesics and tramadol should be the next remedy utilized. Furthermore, a nurse practitioner should also administer skeletal muscle relaxants like tizanidine and cyclobenzaprine (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
Non-pharmacologic interventions are also effective in the management of this condition. Primarily, physical therapy provides a multimodal treatment approach, which offers the best management of this condition. It comprises of therapeutic exercise, rehabilitative ultrasound imaging, traction, manual therapy, modalities and patient education (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
Patient education should include a patient teaching topic such as good posturing and body mechanics to prevent aggravation of the existent back pains. Also, enlightening the patient on the risk factors for disk degeneration such as obesity is crucial in the prevention of such complications.
Follow-up activities include referral to the physiotherapist to help the patient adopt an effective physical exercise regimen that can reduce this challenge (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
Obesity
Central to the diagnosis of obesity is the BMI calculation that will point out to one being obese or not through indicating the adiposity of an individual. However, reliable measures of adiposity are evident through tests that include but not limited to hydron densitometry and computed tomography. Also, laboratory tests such as lipid profile can also point out one’s obese status (Winkelman, Ignatavicius, Workman, &Ignatavicius, 2013).
Therapeutic management includes both pharmacologic and non-pharmacologic management. Pharmacologic management comprises use of drugs that will mainly reduce appetite and peripheral gastric uptake. Such drugs include but limited to sympathomimetic drugs like phentermine and pancreas lipase inhibitors (Orlistat) (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
On the other hand, non-pharmacologic interventions predominantly entail the use of patient education. Lifestyle modification to include exercise, good dietary practices and aversion of alcohol drinking are all crucial topics that must form part of the patient’s teaching plan (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
Follow-up activities for this patient must include regular check-ups for assessment of the weight and development of other co-morbid conditions such as diabetes. Additionally, referring the patient to the nutritionist is also crucial for the maintenance of good dietary practices (Winkelman, Ignatavicius, Workman, &Ignatavicius, 2013).
Hypercholesterolemia
Diagnosis of this condition is possible through lipid profile test that will indicate the level of the various lipid components such as triglycerides, low-density lipids and high-density lipid levels (Winkelman, Ignatavicius, Workman, &Ignatavicius, 2013).
Therapeutic management should include pharmacologic management that entails lipid-lowering drugs like statins (Atorvastatin) and fibric acids like (Gemfibrozil). For the drugs to be more effective, lifestyle modification is also necessary. Good dietary habits, the inclusion of exercise in daily activities and reduction of alcohol intake are all necessary lifestyle adjustment initiatives (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
Referral to the physician is inevitable if the patient does not show signs of improvement with the combined pharmacologic and non-pharmacologic interventions used. Also, linking the patient to support groups is another follow-up activity that can ensure the success of the management of this condition.
Evaluation of Priority Diagnosis
The priority diagnosis for this patient is the low back pain. Such is the case given that it restricts his activities of daily living. An evaluation of this diagnosis is thus crucial to the further understanding of the condition.
Normal Development versus Disorder
Normally, the lumbar vertebral region, like all the other vertebral regions, contains a shock absorbing intervertebral disk that separates the each vertebral body. Additionally, the lumbar spine has muscles and ligaments that stabilize it and the pelvis as one proceeds with daily movement (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
However, in the face of a low backache, the muscles become weakened, and the intervertebral discs undergo degeneration resulting in pain during the movement (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
Physical and Psychological Demands of Lower Back Pain
Physical demands of this condition on the patient may include disruption of activities of day-to-day operations, sleep disturbance, and sexual activity disruption (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013). All these physical effects are due to the back pain.
On the other hand, psychologically, depression is inevitable because the patient is not happy with his inability to accomplish the personal tasks (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013). Also, there is a loss of employment which affects one and the family psychologically through the development of stress. Besides, coping with the condition may also cause a psychological breakdown given that the patient and family have to make many adjustments. As such, they end up suffering psychological distress secondary these life changes.
Key Concepts for Discussion with Patient and Family
The nurse practitioner must have a comprehensive teaching plan if he/she is to manage this condition effectively. Key concepts to include in the educational plan are the practical details of the condition (risk factors, etiological factors, pathophysiology, and management strategies). Besides, the nurse must incorporate lifestyle adjustment practices such as dietary modification to eliminate the possibility of obesity, which worsens this condition. Moreover, teaching the patient coping strategies is also another essential component of this teaching plan (Winkelman, Ignatavicius, Workman, &Ignatavicius, 2013).
Key Interdisciplinary Team Personnel
Central to the effective management of lower backache is the nurse collaborating with various health care professionals like the nutritionist, physiotherapist, and radiologist. The nutritionist will help the patient to adapt good dietary practices whereas the physiotherapist will help to devise exercises that will facilitate the rehabilitation of the patient (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013). Finally, the radiologist will assist in conducting the radiological examinations of the patient.
Facilitators and Barriers to Optimal Management
A primary facilitator of the management of this condition is a comprehensive physical therapy. An extensive physical therapy entails interventions such as therapeutic exercise, rehabilitative ultrasound imaging, traction, manual therapy, modalities and patient education (Foster, 2011). With such interventions, the patient is on course to receiving the best management.
On the other hand, optimal management of lower backache faces certain barriers. A case in point is the poor utilization of guidelines and recommendations during clinical management of this condition. For instance, some health care professionals use symptomatic treatment without the combination of other interventions such as therapeutic exercise. Moreover, failure of medical personnel to adhere to return to work advice of 6weeks after diagnosis is another cause of suboptimal management of this condition (Foster, 2011). Proceeding with daily work hinders the recovery of the patient.
That said, strategies to address these barriers are thus necessary. A primary measure is the use of the best universally recognized evidence-based guidelines that come from quality research. Integration of such guidelines will supersede the barrier of confusion and use of ineffective guidelines. Another strategy is emphasizing the need for a return to work advice (Foster, 2011). An action of this kind will reduce the chances of recurrence of this challenge.
References
Buttaro, T., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2013).Primary care: A collaborative practice (4th ed.). St. Louis, Mo.: Elsevier Health Sciences.
Centers for Medicare & Medicaid Services,. (2016). Medicare Coverage Database – Centers for Medicare & Medicaid Services. Cms.gov. Retrieved 12 December 2016, from https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx?KeyWord=hypertension&bc=AAAAAAAAAAAQAA%3d%3d&
Foster, N. E. (2011). Barriers and progress in the treatment of low back pain. BMC medicine, 9(1), 1.
Winkelman, C., Ignatavicius, D., Workman, M., &Ignatavicius, D. (2013). Clinical companion, Ignatavicius Workman, Medical-surgical nursing (1st ed.). St. Louis, MO: Elsevier Saunders.
