Primary Care of Acute Clients-Families Across the Lifespan

1 Primary Care of Acute Clients/Families Across the Lifespan August 8, 2022 2 Tinker Bell is a 39-year-old married Caucasian female, DOB 1/1/1983, who is a reliable historian. Subjective CC: "I hurt my lower back 3 days ago and am in a lot of pain." HPI T.B. is a 39-year-old married Caucasian female with PMH of Celiac disease, presenting to the clinic with her husband for a complaint of lower back pain that started 3 days ago after one month of commuting two hours one way to a new job. Patient reports 5/10 sharp pain in the lumbar region of her back that radiates to her right buttock. Pain is exacerbated by movement, predominately going from a sitting to a standing position, and is relieved with rest. Patient reports using heat therapy and OTC Tylenol 650mg PO every 6 hours as needed for pain relief. Patient denies extremity weakness, recent trauma, heavy lifting, strenuous exercise, urinary incontinence or retention, recent anesthesia, fevers, or unintentional weight loss. Past Medical History: ● Medical: ○ Celiac disease ● Surgeries: ○ Breast augmentation (2012) ● Hospitalizations: ○ none ● Preventative care: ○ Covid vaccine - Refused ○ Eye exam: 2/1/2022 – Normal ○ Dental exam: 3/1/2022 – Normal ○ Pap smear: 4/1/2020 - Normal Allergies: No known drug, food, or environmental allergies Medications: Multivitamin PO daily Tylenol 650 mg PO PRN 4-6 hours for pain Social History: Denies alcohol consumption Denies smoking 3 Denies recreational drug use Reports 300mg caffeine intake daily (energy drink) Employment: Commercial photographer Family History: Father is living. Reports arthritis. Mother is living. Reports hx of breast cancer. ROS Constitutional: Denies fevers, fatigue, lightheadedness, and feeling unwell. Neurological: Denies tingling, numbness, and shooting pain in upper and lower extremities. Cardiovascular: Denies palpitations, lower extremity edema, and chest pain. Pulmonary: Denies coughing, dyspnea, and wheezing. Musculoskeletal: Reports lower back pain that intermittently radiates to right buttock. Reports difficulty bending over. Denies difficulty turning side to side. Psych: Denies depression and anxiety. Objective Vital Signs HR 89 BP 116/62 Heigh t RR 18 Temp 98.5 F SpO2 97% room air Pain 5/10 Lower back 59 inches (175.25 cm) Weight 170 lbs. (77.119 kg) BMI 25.1 (Overweight) Physical Exam General survey: Well groomed. Mood appropriate. Appears in pain. Follows commands. Neurological: Alert and oriented to person, place, setting, and time. Patient denies numbness and tingling in bilateral upper and lower extremities. Deep tendon reflexes normal in upper and lower extremities. Muscle strength 5/5 bilaterally. Cardiovascular: S1and S2 noted. No abnormal heart sounds present. Radial and dorsalis pedis pulses 2+ bilaterally. No leg swelling present. Pulmonary: Respiration rate within normal limits. Anterior and posterior lung sounds clear. No dyspnea noted. Musculoskeletal: Shoulders and hips equal height bilaterally and nontender. C7-L5 spinous process is palpable, midline. L5-S1 is tender to palpation. Patient can bend to 90 degrees when attempting to touch toes before pain level increases to 8/10 from 5/10. Patient reports discomfort and difficulty laying flat on exam table. Moderate discomfort reported during straight leg test. Labs, radiology, and other pertinent studies Labs and imagining is unnecessary Assessment 4 Differentials 1. Low back pain, unspecified [ICD-10: M54.50] a. Due to the age of this patient, her recent sedentary lifestyle, long periods of sitting in a vehicle, and symptoms, unspecified low back pain should be the diagnosis of this patient due to the typical self-limiting pain that does not warrant imaging (Mancini et al., 2021). If the low back pain persists longer than 4 weeks, the patient should be reevaluated for the cause of the pain (Mancini et al., 2021). 2. Strain of muscle, fascia, and tendon of lower back, initial encounter [ICD-10: S39.012] a. While a muscle, fascia, or tendon strain of the lower back can be a cause of low back pain, this diagnosis is unlikely because strains are caused from sudden injuries or over use that cause the muscle fibers or tendons to become over stretched or torn and this patient denies injuries or activities that would result in this type of injury (Pilitsis, 2022). 3. Lumbago with sciatica, unspecified side [ICD-10: M54.40] a. This diagnosis is unlikely due to the lack of numbness, tingling, or anesthesia because these symptoms are indicative of a radicular process (Hsu et al., 2021). However, if pain persists longer than 1 month, imaging should be done to assess for compressed nerves that could be causing the low back pain. Plan Diagnosis 1. Low back pain, unspecified a. Diagnostics i. Labs and diagnostic imaging are unnecessary for initial presentation (Mancini et al., 2021). b. Medications i. Naproxen 500mg PO Q12hrs PRN pain (Mancini et al., 2021). ii. Cyclobenzaprine 5mg PO TID PRN muscle spasms (Mancini et al., 2021). iii. Vitamin B12 fast dissolve 2000µg sublingually daily (Mancini et al., 2021). c. Nonpharmacologic treatment i. Physical therapy ii. A heating pad placed on the lower back can relieve pain from muscle spasms (Knight et al., 2022). iii. CAM therapy 1. Chiropractic care (Knight et al., 2022). 2. Acupuncture (Knight et al., 2022). 3. Massage therapy (Knight et al., 2022). d. Patient education i. Limit bed rest to less than 48 hours as immobility can exacerbate pain and prolong healing (Mancini et al., 2021). 5 ii. Low back pain is usually self-limiting and physical therapy with prescribed medications should relieve pain and improve mobility (Mancini et al., 2021). iii. Walk as much as possible. iv. Do not sit on a sofa or a soft cushioned chair. Sit on a straight-backed chair to maintain lumbar lordosis (Mancini et al., 2021). v. Maintain normal weight (Mancini et al., 2021). vi. Reduce stress level (Mancini et al., 2021). vii. Maintain good posture and lift objects with proper lifting technique (Knight et al., 2022). viii. Remain active (Knight et al., 2022). ix. Educate patient on red flags that would warrant immediate evaluation in the emergency department such as numbness or weakness resulting in falls, urinary incontinence or retention, or fever (Knight et al., 2022). e. Follow up i. Follow up in 2 weeks to evaluate improvement.