General Patient
Information
·
ML is a preparatory class teacher aged 56
years. She is of Hispanic origin, having been born and brought up by her
Hispanic parents who moved to California in the early 90s. Mary is married and
has two children, a son and a daughter who are in their teenage years.
·
Source: the patient was her source and
her reliability being fair
Current health status
·
ML has been complaining of exacerbation
of her back pain that has indicated an escalation within the last two weeks.
Within the last few weeks, she has relied on a borrowed wheel chair to use
around the house due to the pain. According to her, it starts as an aching pain
that becomes sharp with a form of movement. The pain according to her gets
worse if she spends long durations sitting and is normally relieved whenever
she leans forward. Occasionally the pain radiates around her legs. The patient
has a degenerative joint disease as well as spinal stenosis, indicating that
she fell severally in her younger years, from where the pain started. The use
of Lumbar x-rays and MRI in the WebCIS have indicated that there is the
presence of severe spondylosis with the foraminal and central canal narrowing
about the degenerative variations.
·
ML has additionally reported a sore
throat that has been prevalent for the past one week, with white pus in the
back of her throat. The patient exhibits a mild cough producing clear sputum
that has not subsided but does not have major dyspnea. The patient additionally
says that the pain is mostly felt on her left side that she believes around her
8th rib space. She further says that she recorded a fever of more than 100
degrees Fahrenheit the previous week but negates any of the other
constitutional symptoms as chills, night sweat or being afebrile. The ML has
additionally denied having nausea, excessive fatigue, dysphagia, drooling or
vomiting. ML has not taken any medication that was meant to relieve pain
although she asserts that she has been improving over the past three days.
·
ML had her menstrual cycle two years ago
and reported that it was normal as the others that had passed. The pain in her
back and sore throat has affected her sexual life over the past month; an
attribute she believes has been affecting her husband also. Overall, ML asserts
that she has always been satisfied with their sexual relations until the
complications started emerging, making it hard uncomfortable.
Contraception Method
·
The patient is neither pregnant, and
neither has she been taking oral contraceptive nor any other form of hormone
therapy.
Patient History
·
ML has been treated for hypertension,
allergic rhinitis, depression, tobacco abuse as well as diabetes mellitus 2.
She has additionally been treated for GERD and colonial polyps.
·
The use of Lumbar X-rays and MRI in the
WebCIS have indicated that the presence of severe spondylosis along with
central canal and narrowing of the foraminal due to the degenerative changes.
She has been standing on a regime of methadone 40mg daily in an attempt to
relieve her back pain.
·
She had osteomyelitis in her second left
toe, s/p amputation in 06/08/15, breast cancer 2004 s/p mastectomy and
tamoxifen, left foot cellulitis exhibiting abscess from foreign body 2008 s/p
and left medial malleolus fracture 2010.
·
Regarding hospitalizations, ML has
surgeries and procedures that involved the amputation of the left 2nd toe at
disal phalanx, appendectomy in 2003, right mastectomy in 2004 and hysterectomy
2012.
Medications
·
Dermotic Oil, 0.01% ear, drops bid
·
Docusate Sodium 100mg prn
·
Lipitor 80mg po qhs
·
Neurontin 300mg, taken 900mg tid
·
Mg-oxide 400mg, take 1600mg bid
·
Nexium 40mg qd
·
Citalopram HBR 40mg takes 1.5tabs qd
·
Enalapril 2.5mg qd
·
Aspirin 81mg qd
·
Kenalog, 0.1% cream, applied bid
·
Metformin HCl 850mg tid
·
Furosemide 80mg bid
·
Lidoderm, 5% patch, applied q12 hrs prn
·
Wellbutrin SR 100mg bid
·
Detrol LA 4mg qd
·
Methadone 20mg
·
The assessment of the allergies that the
patient exhibits makes it apparent that she is allergic to valdecoxib,
Vancomycin, and prednisone
Health Maintenance
·
The details relating the maintenance of
the patient’s health are not clear. The anticipation is that these records are
going to be obtained from her PCP. The moment that her TTP will be treated with
the follow up arranged with her PCP and additional screening is to be
encouraged.
Family Medical History
·
The father is MI at the age of 76,
hypertension and is still alive. The mother, on the other hand, has colon
cancer, diabetes, and hypertension and is still alive also. The overall
assessment of her general family reveals that there have been significant cases
of heart disease, stroke, and melanoma as well as breast cancer.
·
The patient has been smoking for more
than 25 years and is currently smokes two packets a day. She also takes alcohol
three times a week.
Gynecologic History
·
ML has two children, a son and a
daughter who are both in their teens. She has never had any complications in
giving birth, and neither has she ever miscarried.
·
On the case of sexually transmitted
infections, she asserts that she has previously had bacterial infections, with
the worst one being herpes while she was in college. She has never contracted
either hepatitis A or B viruses and her recent HIV test indicated that she was
negative. She used acyclovir (Zovirax) and valacyclovir (Valtrex) in treating
in herpes.
·
ML’s menarches reveal that she had her
last smear test in 2010 and was normal. All the subsequent smear tests have
been normal. The 56-year-old patient had a last menstrual period two years ago
and denied the presence of any rectal or vaginal bleeding. The assessment of a detailed comparison of
her body density evaluation in 2010 against the one in 2016 indicates that
there has been a slight decline in the overall bone mineral density at the hip.
According to the patient, there was a mammography that was conducted three
weeks ago and the results of the study indicated a normal outcome.
Personal Social History
·
The patient has been living with her
husband in California in an apartment with their two children. With the
challenges that ML has been facing the children and her husband have been doing
most of the work at home. Hispanic in the region maintains close, and the ties
have been vital in the assessment of ML’s condition and seeking medical
assistance. The Hispanic community in the region has even offered money
assistance through contributions that are meant to assist her to seek specialized
medical assistance.
·
ML is a university graduate having
majored in education and works as a preparatory teacher. The husband, on the
other hand, is an IT specialist in of the multinational corporations in
California. The although the family has not been experiencing financial
difficulties, ML’s condition has made it impossible for her to work, making the
husband the sole breadwinner.
·
ML indicates that she has never suffered
any form of abuse or forced sex from any part throughout her life. Her occupational
does not exemplify any major issues that could contribute to her state of
health. It, however, follows that the long durations spent supervising her
students have been a constant trigger of her back pain.
·
The patient asserts that she has been
smoking for the greater part of her life and has been taking alcohol
constantly, approximately three times a week but asserts that it has never been
an issue of concern to her or the immediate family. She further does not engage
in any additional exercise other than the normal works she takes in her class
as well as the occasional walks around the school compound to check on her
students.
·
ML denies taking caffeine regularly and
that she has been sleeping well before the start of the back pain.
Additionally, she asserts that she checks on her diet well, ensuring that the
food eaten is mostly organic and a balanced diet.
The Assessment of
Systems
·
The general assessment of the patient is
clear that the patient denies having fatigue, chills fever and decrease in appetite.
ML has been sleeping well until the back pains started when she could not sleep
due to the pain in her back. She maintained a good PO intake until the previous
study when started vomiting.
·
Skin: the patient asserts that she does
not have any rashes or lesions anywhere on her body
·
HEENT: she asserts that she does not
exhibit double vision, blurry vision as well as changes to her acuity. She
never wears glasses
·
The ears: she asserts that she has not
recorded any changes top her hearing
·
Assessment of the throat, nose/ mouth
and teeth follows that the patient confirms to exhibit sore threat with minimal
congestion although with pus at the back of her throat. She, however, denies
dental pain and rhinorrhea.
·
Cardiovascular- ML denies having any
cases related to palpitation or chest pain. She further denies having any
claudication in the lower extremities.
·
Gastrointestinal: there are between 1
and three bowel movements occasioned by constipation that she relieves via the
use of docusate sodium. She has not experienced any challenges that are
associated with the black or bloody stool. She has additionally not experienced
any form of abdominal pain or diarrhea.
·
Hematopoietic: the patient indicates
that she does not have any issues as excess bleeding or easy bruising.
·
Genitourinary: ML indicates that she has
been having intermittent urinary incontinence when she takes neurotin but has
no dysuria, urgency or any increase in the frequency.
·
Psychological and mental health: ML
exhibits a normal affect in additional to a behavior that is normal to her
stature and health situation.
Physical Exam
·
Vital signs: weights 96kg, pulse 55, temp 35.2 degrees
Celsius, RR 17, 99% on RA, height 155 cm and BMI 39
·
General: a pleasant, healthy looking
lady with some distress as a result of her back pain, has been quiet and mildly
drowsy.
·
Skin: the skin does not have rashes or
lesions on the upper extremities, the face, chest, back or abdomen.
·
Lymph nodes: there were no cervical,
periauricular, axillary lymphadenectomy
·
Chest: scattered wheezes were heard
bilaterally with no rhonchi. The egophony produced “E” sound similarly on all
the lobes
·
HEENT: no sublingual or scleral icterus,
with the oropharynx being clear and mucus being moist. The pupils are round,
equal moreover reactive to light.
·
Neurologic: sensation and motor grossly
intact
·
Extremities: no clubbing, cyanosis or
edema
·
Heart: regular rhythm and rate without
murmur gallop or rub
Laboratory Data
·
06/22/16– Na 144, BUN 13, K 5.7, Cl 102,
Cr 1.3, BUN/Cr 13, Est GFR 49.02, Mg
1.2, Ca 8.3, P 4.2, AST 36, ALT 37, Anion gap 12
Differential Diagnoses
·
The back pain: the back problem has been
the major challenge for ML, with the narrowing of the spinal stenosis and
foraminal due to the degenerative disease being the core cause of her
situation. The alternative causes of the back pain as sprain or strain about
the vertebral fracture, lumbar vertebrase, infection, neoplasm or referred
pelvic pain being ruled out (Itz, et al., 2013). The assertion is that strain
and sprain are accountable for almost 70% of the low back pain although the
age-related degenerative changes; disc herniation and spinal stenosis are the
subsequent common causes that account for almost 16% of chronic back pain
(Pillastrini, et al., 2012). Considering the chronic nature as well as a rate
of progress of ML’s disease, degenerative changes along with stenosis and
herniation are the most probable causes of the pain.
·
The management strategy at this point
will be on the controlling of the pain that ML has been experiencing. The
patient has been on methadone regimen for a long time and has developed an
emotional and physical reliance on the drug (Issack, et al., 2012). It is
imperative that she continues taking methadone 20mg in the morning, 5gm at
lunch, 10mg in the evening and 10 mg before going to bed. The management plan
will encompass a careful avoidance of NSAIDs due to the possible side effects
it has which include hypertension, diabetes and tobacco abuse (Olsen, et al.,
(2012). It is additionally necessary that she stays ambulatory with a
supporting Walker allowing her to walk with some forward flexion.
·
On the case of a sore throat, ML has
been afebrile with the HEENT exam not being indicative of any signs of
bacterial pharyngitis as exudates or tonsillar swelling. It is additionally
evident that the physical exam is not indicative of pneumonia or any other
infection that would warrant any form of antibiotic therapy (Balagué, Mannion,
Pellisé, & Cedraschi, 2012). Considering the improvements she has noted along
with the time course of the compliant, it is most probable that a self-limiting
upper respiratory tract infection is the main cause and will not benefit from
the use of pharmacotherapy. It is imperative that she contacts her healthcare
specialists if symptoms as difficulty in swallowing, high fevers of challenges
in breathing and worsening of the symptoms.
·
The patient education in the management
of the conditions will revolve around ensuring that she moves around more
often. Additionally, addressing her alcohol and smoking pattern by reducing if
not quitting will additionally be the issues she should take into
consideration.
·
The follow up care will encompass the ML
reporting to the healthcare specialist for checkups on a weekly basis as well
as whenever she believes that the symptoms are worsening.
References
Balagué,
F., Mannion, A. F., Pellisé, F., & Cedraschi, C. (2012). Non-specific low
back pain. The Lancet, 379(9814), 482-491.
Issack,
P. S., Cunningham, M. E., Pumberger, M., Hughes, A. P., & Cammisa Jr, F. P.
(2012). Degenerative lumbar spinal stenosis: evaluation and management. Journal
of the American Academy of Orthopaedic Surgeons, 20(8),
527-535.
Itz,
C. J., Geurts, J. W., Kleef, M. V., & Nelemans, P. (2013). Clinical course
of non‐specific low back pain: A systematic
review of prospective cohort studies set in primary care. European
Journal of Pain, 17(1), 5-15.
Olsen,
A. M. S., Fosbøl, E. L., Lindhardsen, J., Folke, F., Charlot, M., Selmer, C.,
... & Hansen, P. R. (2012). Long-Term Cardiovascular Risk of Nonsteroidal
Anti-Inflammatory Drug Use According to Time Passed After First-Time Myocardial
Infarction A Nationwide Cohort Study. Circulation, 126(16),
1955-1963.
Pillastrini,
P., Gardenghi, I., Bonetti, F., Capra, F., Guccione, A., Mugnai, R., &
Violante, F. S. (2012). An updated overview of clinical guidelines for chronic
low back pain management in primary care. Joint Bone Spine, 79(2),
176-185.
Sherry Roberts is the author of this paper. A senior editor at MeldaResearch.Com in custom nursing essay writing services services if you need a similar paper you can place your order for college essay writing services.
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