I need help with reply
Jennifer
Week 5 Discussion
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.
Mr. Payne is a forty-five-year-old truck driver complaining of “two weeks of sharp, stabbing back pain mainly on the left side after lifting a 10-lb.box.” According to the case study, he expressed at the visit, the pain was better after three days of using ice and taking Ibuprofen therapy. After playing softball with his daughter last weekend, the pain became constant over the past week and made it more difficult to get out of bed. He said the pain is a sharp pain that starts at the left lower back area that travels down his left leg to his left ankle. He said he initially tried ibuprofen 400mg every six hours for three days and switched to Naproxen 250mg daily for five days that helped some. He said the pain is worse with movement of the back, when he sits for a long period of time, but is better when he lies down. He has a history of experiencing back pain in the past that resolved after two to three days. He said that this is the worst pain he has experienced during this visit.
Mr. Payne denies any recent illness, injury, or trauma events. He denies having any numbness or weakness in his legs. He denies any urinary frequency, painful urination, bowel concerns or bladder control issues. No fever, chills, nausea, vomiting, or weight loss mentioned. He denies any specific night pain concerns. Since he works as a truck driver, he normally is required to lift an average of 20-35 pounds for approximately 4 hours of the day. He was a smoker a pack a day for 20 years but quit 2 years ago. He drinks alcoholic beverages, usually one to two beers on weekends occasionally. He denies illicit drug usage. He has history of one sex partner that was diagnosed with HIV. He said that his current viral load count is low and that he is currently taking the pre-exposure prophylaxis treatment that he started approximately 2 years ago when partner was diagnosed. He said he does have a daughter from a previous relationship. He has a history of hypertension and hyperlipidemia. He denies any surgical history and is currently taking Chlorthalidone 50mg and Lisinopril 40mg daily for hypertension. He takes simvastatin 40mg daily for hyperlipidemia and he takes Tenofovir disoproxil fumarte/Emtricitabine as directed for HIV pre-exposure treatment. He has recently tried ibuprofen and naproxen as mentioned above due to the back pain he has been experiencing. He has no known drug allergies.
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?
Mr. Payne had his vitals taken on the visit. They were as follows, temp 98.6 orally, HR 80, respiratory rate 12, BP 130/82. Pain 7/10 on the pain scale. His weight was 170 pounds and BMI of 24 kg/m2. The physical exam was conducted to include inspection of posture, contour, symmetry, palpation of bony prominences and range of motion testing. Patient had a sitting, standing, and lying on back exam done. Upon sitting exam, he had no CVA tenderness, reflexes were 2+ in both knees, and 1+ in both ankles. His motor exam revealed 5/5 strength throughout the lower extremities and sensory exam was normal. His lungs were clear on auscultation, and he had a normal cardiac exam with a regular rhythm on auscultation. His standing exam revealed normal curvature, symmetry, and some tenderness on palpation of the left lumbar paraspinal muscles with increased tone. Mr. Payne ambulated normally and can walk on his heels and toes without difficulty. He had a full range of motion in all directions and pain with movement. He could perform deep knee bends with no pain change with squatting.
During his supine exam, his abdomen was inspected, palpated, and auscultated for abnormalities and was normal. He had a straight leg raise test done and was positive at 60 degrees on the left and negative on the right. His FABER test that was done was negative and his sacroiliac joint was nontender. No muscular atrophy was seen in his lower extremities upon examination. The provider reviewed medication regimen at the visit and ordered renal function, STI and HIV testing to be done prior to the next follow-up visit to be done. The providers discussed that no further lab or imaging studies were needed after the physical examination was completed. If the patient was able to get the recommended labs that were ordered prior to this visit it would have been helpful. The CBC, CMP, HIV and STI testing including a urinalysis would have been helpful prior to the initial examination to help rule out an infectious process (Pangarkar et al., 2019).
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?
Lumbar strain (S33.5)-This diagnosis was chosen since the patient is a truck driver and is required to lift 20-35 pounds approximately 4 hours a day that he works. He mentioned that he noticed the pain after lifting a 10-pound box. He described that with movement and sitting the pain is worse, and he is sitting for long periods of time driving the truck.
Degenerative joint disease (M19.90)- This diagnosis was chosen initially since the patient said that he has been experiencing a history of back pain that normally resolves after two to three days on its own. Due to his occupation of frequent lifting of objects of 20-35 pounds over extended amount of time it could lead to this type of arthritic pain.
Spondylolisthesis (M43.1)-This diagnosis was chosen since Mr. Payne described that the pain had initially resolved after use of NSAID therapy but when he engaged in a sporting activity such as softball with his daughter it returned. He described that the pain became more constant and worsened over the week. Pain being brought on by sporting activities can indicate Spondyloisthesis.
After taking the history and the providers performing a physical examination, Mr. Payne was diagnosed with Lumbar radiculopathy due to disc herniation (M51.16), likely at the L5/SI level. This was determined when the patient expressed in his history that the pain radiated down his left leg to his ankle, and it was increased with movement and prolonged sitting. He expressed that he got some relief when he lied down. Upon physical examination of lying on his back, he had a positive at 60 degrees on the left on his straight raise leg test which is usually indicative of herniation (Shiban & Meyer, 2019).
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?
At the initial visit, Mr. Payne was advised of the diagnosis and treatment options. The providers discussed with him that his overall prognosis was good and that his back pain should resolve. He was advised that this back pain may recur due to his current occupation, and he would need to speak with physical therapists about a specific plan due to his occupational requirements. He was given a patient teaching handout on back pain to read. The providers recommended increasing the dosage of Naproxen to 500mg twice a day with food. He was advised to try heat wraps. He declined to try a muscle relaxant due to his occupation. He was referred to physical therapy to develop an exercise program and was to follow-up within 4 weeks. He was also advised to check his blood pressure and keep a log of readings. He was advised to call sooner if he experiences increased pain, no improvement in symptoms or if he develops any new symptoms like neurological deficits.
At the moth follow-up visit, Mr. Payne continued to have back pain but expressed that he had some improvement with the recommended treatment from physical therapy. Another exam was performed and did not show any red flags or worsening with current treatment. To help the patient progress faster, Mr. Payne was offered a referral to see an osteopathic physician for spinal manipulation. The patient was also switched from Naproxen to Meloxicam 7.5mg BID with food to see if that helps with the pain. He was advised to continue his current prescribed physical therapy regimen.
Mr. Payne was contacted by the staff via phone to see if there was improvement after 2 weeks of initiating the new treatment. He said that his symptoms had improved, and he was doing significantly better. He discussed with staff that he was continuing to improve with the exercises recommended by physical therapy and spinal manipulation seems to help. He said he has been tolerating Meloxicam well and starting to decrease the dosage to 7.5mg daily. He has been checking his blood pressure readings and said it has stayed within normal limits while taking the NSAID therapy. He agreed to continue the recommended exercises by physical therapy and follow-up as needed with staff if he has recurrent episodes or if any worsening of symptoms.
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