Analyzing the disorder
Order Instructions:
HPI
A 40-year-old Asian American male, who works as a roofer, complains that three days ago he was lifting a heavy object at work, following which he got low back pain. The pain is in the middle of the back near his waist. The pain increases when he bends forward and he is experiencing numbness and tingling in the toes of his right foot. He has had similar symptoms before, but it has not been so bad in the past. This is the worst he has had because in the earlier instances, he has never had the tingling sensation in his right foot before.
In the past, he got better with rest and some Ibuprofen. He is worried that he will not be able to continue his work and make money. He is out of work as a result of the pain. He has a lot of difficulty getting sleep at night. He has started taking some of his friend’s medication and it seems to help.
He has pain in the mid lumbar area, which radiates to the right buttock. He also has numbness and tingling down the back of his right thigh to his toes. The pain and numbness has been increasing since the problem started three days ago. He has tried over-the-counter Ibuprofen and some stretching exercises, but it does not seem to help. He has not sought any medical care yet. In the past, the pain had just gone away, but this time the pain is persistent. There is a gradual worsening of his symptoms and he is concerned about the pain that has been increasing steadily over the past three days. He is wondering whether he has a herniated disc. His major concern is that he has no health insurance and will be missing work.
PMH
He has had similar pain in the past, but it was not so severe. He saw a chiropractor around two or three years ago and that gave him some relief. Otherwise, the patient has no chronic medical problems. He does not seek medical care on a routine basis.
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He has had no diagnostic measures in the past. He has never had any blood work reports, CT scan reports, X-ray reports and so forth done in the past. He has been gaining weight over the past few years and does not do any stretching exercises before
© 2007 South University
work. Patient does not have any other risk factors. There are no records of any past surgeries. He has neither had any significant illnesses in the past nor any hospitalizations.
ROS
Pain in the mid lumbar area radiating to the right buttock. There is a tingling sensation that goes down the back of his right thigh to the toes. He does not have urinary or bowel incontinence. No nausea, vomiting, or fever. He denies abdominal pain and pain with urination. There is no gross hematuria.
MEDICATIONS
Patient does not take any prescription medications, only over-the-counter Ibuprofen. He is using 800mg of Ibuprofen every four hours. Patient is compliant with the prescribed regimen; in fact, he could be using too much. Patient is seeking care because of the increasing pain. He has tried chiropractic manipulations in the past for low back pain.
ALLERGIES/REACTIONS
He is allergic to Penicillin. It has caused a rash in the past.
SOCIAL HISTORY
This patient works for a local roofing company and makes $30,000.00 per year, which is just a little over the minimum wage. He has a high school education certificate and makes just enough money to get by. He has no health insurance. The patient feels that the last thing that he wants to do is spend money on healthcare. He feels his body will get better on its own, and so he can just keep working. He made the appointment at this outpatient clinic because his friends told him about it. He was not sure where to go for help. He has decreased access to healthcare because he is not aware of the services available. The patient has had essentially no healthcare to date. The patient states that he is starting to realize that his body will not last forever at his current position as a laborer.
The patient is divorced and thinks he was a failure as a husband. He is behind in alimony payments. His wife is alive and well without any medical problems. They do not communicate anymore. They have no children. He would like to try and get back together with her, but she refuses to speak to him. He has been holding himself back
Page 2 of 5from expressing the amount of stress he has in life for many years. He thinks he is becoming depressed as a result of this. His parents still live in the area and he sees them every weekend. He has friends from work and they do social things together. The patient has not sought any emotional support from anybody. There is no element of family dysfunction. He becomes easily stressed out. He lives in social isolation from his community. The patient has always taken his health for granted and not thought much about it in the past.
HABITS
Smoking: Non smoker
Alcohol: Drinks at bars on weekends to excess with his friends
Substance abuse: He smokes marijuana.
DIET HABITS
He skips breakfast and eats at fast food restaurants twice every day. He sips coffee and caffeinated beverages throughout the day. The patient feels that his job gives him enough exercise and so he need not do anything else. He plans to go on a “diet” soon to lose the weight he has gained over the past few years, but is not sure about the diet he is going to follow.
WORK HABITS
The patient works as a roofer. He has had other labor-intensive jobs in the past that do not require an educational background. He does not enjoy his job. He knows it is a dead end job and wants to go to school. He is originally from United States and lives in a suburban community where resources are easily accessible, but he is not aware of them.
FAMILY HISTORY
Both parents have hypercholesterolemia. His 65-year-old father has prostate cancer. Both parents are being treated with medications for their high cholesterol levels. He has no siblings. There is a remote history of heart disease in his relatives.
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© 2007 PHYSICAL EXAMINATION
Vital Signs: Ht: 6”; Wt: 220; WC: 40; BP: 120/78; T: 97 po; P: 92 and regular; R: 18 non-labored
HEENT: WNL
Lymph Nodes: None
Lungs: Clear
Heart: RRR without murmur
Carotids: Not examined
Abdomen: Android obesity, otherwise benign
Rectum: Not examined
Genital/Pelvic: NA
Extremities, Including Pulses: 2+ pulses in the lower extremities
Neurologic:
Mental Status: Alert and oriented
Cranial Nerves: II – XII intact
Motor Strength: Upper extremities equal strength 5/5.
Lower extremities: decreased strength of right leg with resisted extension; patient complains of pain in posterior thigh.
Sensation (light touch, pin prick, vibration, and position): Decreased sensation of right leg along L5 : S 1 dermatome to pin prick stimulation compared with the left.
Reflexes: DTRs 2+ in upper and lower extremities
Cerebellar function intact—Romberg test is negative; heel-to-toe walking is steady.
Postive straight leg raise on the right at 20 degrees.
LAB RESULTS/RADIOLOGICAL STUDIES/EKG INTERPRETATION
Lab Results
CBC: WNL
UA dip stick: WNL
Radiological Studies
Plain film of lumbar spine: loss of disc height at L5 to S1. Mild degenerative changes of lumbar vertebrae.
MRI: moderate disc bulge at L5: S1.
EKG: Not performed
SAMPLE ANSWER
Analyzing the Disorder
Common low back pain affects more than two thirds of people aging over 40 years. It a rampant problem in the society on the basis of its direct cost associated with health care as well as its socio-economic ramifications. Ten percent of the people with low back pains fear that the pain may evolve to become a chronic case. With reference to the case study of the 40 year old Asian American man, the cause of his musculoskeletal condition is thought to be caused by physical straining especially lifting heavy loads (Leg Numbness, Tingling Feet and Toes. (Dawson, n.d.).
From the signs and symptoms of the subject in the case study, it can be suspected that he is suffering from DDD. The herniating of the disc may occur suddenly or gradually, especially after lifting a heavy load from the ground. The disorder is the most prevalent cause of disability among the middle aged persons.
Pathophysiology
His suspicion that he has a herniated disc in the lumbar spine which is probably pressing the sciatic nerve is likely to be true. Herniation of the nucleus pulposus (HNP) come about when this nucleus breaks dissociates from the annulus fibrosus of an intervertebral disc which is the spinal shock absorber. This leads to degenerative disc disease (DDD).
Signs/symptoms
Pain is the most common disabling symptom in musculoskeletal disorders. The man in the case study has been forced to seek medical attention quite often as a result of the pain. The symptoms characterizing DDD have been manifested by the patient. These include pain, tingling in the lower back, calf or foot, thigh, typically affecting one side. The symptoms worsen when the patient is standing, sitting, lying down and some certain movements such as bending or, as in the case of the subject in the case study, lifting objects from the ground (Degenerative Disc Disease Progression over Time. (n.d.).
Progression trajectory,
The progress of lumbar degenerative disease is slow since it also starts as a benign, manifesting its symptoms in a slow rate. According to the case study, the pain tends to increase with time especially during some movements. It is predicted that if one starts experiencing several low back pains at the age of thirties, chances of being in a wheel chair when they reach sixties are high. Although there will be progression in the disc generation, it is not common for low back pain and related symptoms to progress (Disc Disease Progression over Time, n.d.).
Diagnostic testing
The diagnostic of DDD is done by achieved through carrying out various diagnostic studies. Some of the tests carried out include computed tomography, discography, radiographs and magnetic resonance. The discography is able to tell the source of pain experienced by the patient. These studies are, for instance, provocative discography, lumbar radiographs and magnetic resonance imaging. The patient history, physical examination together with these studies is useful in the diagnostic process although they are not in and of themselves ultimate procedures in the diagnosis of pain. The overall diagnosis is therefore determined by the clinical status of the patient and his response to the prescribed treatment (Hasz, 2012).
A reliable explanation on the cause of back pain experienced by patients is obtained through a diagnosis of degenerative disc disease. This is a usual practice during clinical practice. In Diagnosis of these patients is carried out to find evidence associated with degenerative changes. This is done by healthcare providers by use X-ray, Computed Tomography (CT) or MRI scans. The result obtained from the diagnostic tests provides an explanation for the cause of pain. The health care team use the diagnosis as the basis of decisions made on treatment models chosen. In some cases, procedures such as epidural steroid injections and spine surgeries are focused on modifying degenerative changes occurring in the spine. A common belief by most of the healthcare providers and patients is that these diagnostic tests involving MRI or CT scan make out the cause of pain or degenerative disc changes experienced in the spine (Degenerative Disc Disease., n.d.).
Treatment options
Treatment of degenerative disc disease is treated effectively by conservative care which also comprises of medication to manage pain and inflammation. This medication may be administered orally or intravenously through epidural injections. There are many surgery forms available today as a common form of treatment for DDD. The surgeries use different technologies which have to pass a test of time. Different cultures also have their own remedy on how to conservatively intervene against this disorder. However, exercise and physical therapy is cuts across all cultures and interventions. It is worth noting that there is no sure way of treating DDD hence this remains highly difficult and controversial (Alexandre, 2011).
Differentiate the Disorder from Normal Development
The normal intervertebral discs occur between the vertebral bodies which is important in linking the discs together. They form make up to one third of the spinal column in which they also form consist of its main joints. Normal discs play an important role in providing mechanical support through constantly transmitting loads arising from body activity as well as body weight through the spinal column. The spinal column is flexible due to these discs which allow torsion, bending and flexion. There thickness is approximately 7–10 mm thick and have a diameter of 4 cm. The thick outer ring making up the complex intervertebral discs structures are made of fibrous cartilage known as the annulus fibrosus, which also lines a more gelatinous core referred to as the nucleus pulposus. The cartilage end-plates sandwich the nucleus pulposus. With an increase in age and as one grows and there is skeletal maturation, the distinction between the annulus and nucleus decreases and the nucleus becomes less gel like and more fibrotic. The morphology of the disc changes becoming more disorganized
Physical and Psychological Demands on the Patient and Family
The man in the case study is said to be divorced hence he depends on himself through a job he gained through his high school certificate. Having been overwhelmed by challenges of marriage indicates that the patient must have contributed to many problems in the family probably mainly caused by his illnesses.
Key Concepts to Achieve Optimal Management and Outcomes
Optimal disorder management and outcomes with regards to care for the man suffering degenerative disc disease refers to concepts which will improve his wellness and control of problems and psychological factors closely associated with the specific physical conditions and disease. It is important to manage the patient’s cognitive and psychological factors in competence to enable him to manage his own affairs. Also, there is need to manage factors which will ensure motivation, productivity, leadership and healthy workplaces.
With patient-centered care, the family and their patient should be provided with relevant and adequate information which will enable them to manage the disorder ethically. Since it typically arises from the aging process hence it has a tendency to care become a chronic problem. This means that the patient should lead an active life, according to evidence based care, so as to manage their incapacity, whether short term or long term disability.
The Role of Interdisciplinary Team
There is no one person, due to his skills and knowledge can claim responsibility over the success of the team or provision of all care needed by the patient against a disorder such as DDD. Each of the individuals in a team handling the disorder shares a common although each contributes his common goal. The physicians, health care givers and family or friends join the collaborative care teams which align themselves around values and requirements of the patient. The collaborative team should agree on which regenerative therapies would be suitable to repair the degenerated disc or discs.
Facilitators and Strategies to Overcome Barriers
Some of the strategies acceptable by the American Nurses Association are aimed at overcoming self destructive tendencies and promoting patient centered care. In order to restore the patient to back to active life, identification of a proper form of treatment is necessary. The medical practitioners need to use the most appropriate diagnostic procedures before choosing the most preferred therapy for the patient. The patient in the case study has not sought for adequate medical intervention due to economic and social inadequacy.
Alternative ways are available to intervene in the patient’s case. Since he is divorced at the age of 40 years and already takes the blame, this may be a hindrance for his quick recovery. The team is encouraged to provide a lasting solution which is helpful in enabling the man to move on in life. For instance, exploring ways of carefully evaluating the patient’s psychosocial issues with an aim of providing professional counselling will improve the man’s better view of life. Identification of these psychosocial problems would make it easier to counter the factors which quicken the rate at which the disorder becomes chronic. The musculoskeletal disorder related pains will be controlled hence setting the patient toward healing process.
Section II
Plan of Care
According to basic science the disc is not entirely to blame for the pain the pain the patient may be experiencing. This gives the first hint on where the care plan should be directed since it indicates that annulus is not obviously compromised. The care plan considers both indications and diagnostics for either disc replacement or fusion in patients with DDD. However, research hold that the benefits of this process still do not outweigh risks.
How does patient’s socio-cultural background potentially impact the optimal management and outcomes of this plan of care?
From the patient history given, therapy needs to be coupled with a structured rehabilitation program that takes account of cognitive-behavioural therapy and exercise. Research should provide a guide or a framework on this can be done owing to the fact that the man is lonely.
Subjective Data and Objective Data
The patient’s subjective data entails the history taken from his background with regards to his sickness from degenerative disc disease. On the other hand, the objective data will include all other factors related to the effects of the patient’s sickness. These include his divorce, lack of health insurance and poor attention to medical therapy in relation to continuing with work. The issue of family dysfunction, social isolation and poor attention to proper health measures would comprise of objective data.
Assessment
From the history given the patient has not sought for proper medical attention since he only prefers over the counter Ibuprofen. Although he has tried chiropractic manipulation in the past, his problems could not end since this was not the best remedy for this.
Goals of care
· To change the patient’s attitude toward medical attention
· To ensure the patient commences appropriate medication immediately; involving diagnosis and prescription of the right drugs.
· To counsel the patient approach marriage on a better dimension so as to win his wife back.
· To give enable the patients adopt a better lifestyle of nutrition, exercise and work.
How does patient’s socio-cultural background potentially impact the optimal management and outcomes of this plan of care?
The social cultural background of the patient, which is engraved in his attitude to all the issues surrounding him, would make it difficult to implement this plan. However, with an enforced rehabilitation, the plan will work wonders. The negative perception of the patient toward the use of social amenities and services provided would make it a challenge for a successful disease management.
Plan of care
The plan of care for the patient and others like him is to be based on evidence based care. This involves paying serious attention to many aspects other aspects besides responding to patient symptoms and patient history alone. The identification of the right therapy should be ideal to comprehensively solve the problems the man’s seeking. This includes working in collaboration with close family members, employer and other medical experts (Belfer, 2013).
1. Diagnostic test: List, Include IC9 codes.
I. Physical examination
II. Computed Tomography (CT)
III. Provocative discography,
IV. Lumbar radiographs
V. Magnetic resonance imaging
2. Medications: Listnew or changes to dose and time. Make sure you write medication, dose, route and length of time to take if relevant.
v Acetaminophen (such as Tylenol)
v NSAIDs, or non-steroidal anti-inflammatorydrugs. These are:
1. Ibuprofen
2. Naproxen
3. COX-2 inhibitors
(Pain Medications for Degenerative Disc Disease Treatment. (n.d.).
3. Conservative treatments: This would be treatments such as ice, raise head of bed, weigh every day, etc.
Conservative treatment for degenerative disc disorder is based on the patient’s culture. The Asian American people treat DDD by tying a restrainer around the lower back to exert pressure on the part expected to have a lumbar curvature.
4. Education: The education plan for the patients such as the patient in the case study is the introduction social training on how to balance work, family, social life, nutrition and exercise.
5. Collaboration and/or referrals: To ensure the plan is implemented, the county health officer would be mandated to supervise the process. With this position, the officer is capable of influencing all departments and institutions in the country where the individual comes from.
6. Follow-up: The follow-up will comprise of the implementation tools. These include a copy of care plan, sample regimen for the disease and charts for illustration.
References
Alexandre, A., Masini, M., & Menchetti, P. M. (2011). Advances in minimally invasive surgery and therapy for spine and nerves. Wien: Springer.
Belfer, I. (2013). Nature and Nurture of Human Pain. Hindawi, 2013(-), -.
Dawson, E. G. (n.d.). Herniated Discs: Definition, Progression, and Diagnosis. SpineUniverse. Retrieved September 17, 2014,Retrieved from http://www.spineuniverse.com/conditions/herniated-disc/herniated-discs-definition-progression-diagnosis
Degenerative Disc Disease. (n.d.). Treament|Degeneratice Disc Disease Treatments. Retrieved September 18, 2014, from http://www.instituteforchronicpain.org/common-conditions/degenerative-disc-disease
Degenerative Disc Disease Progression over Time. (n.d.). Spine-health. Retrieved September 17, 2014, from http://www.spine-health.com/conditions/degenerative-disc-disease/degenerative-disc-disease-progression-over-time
Hasz, M. W. (2012). Diagnostic Testing for Degenerative Disc Disease. Hindawi, 2012(2012), -.
Leg Numbness, Tingling Feet and Toes. (n.d.). Healthhypecom. Retrieved September 17, 2014, from http://www.healthhype.com/leg-numbness-tingling-feet-and-toes.html
Pain Medications for Degenerative Disc Disease Treatment. (n.d.). Spine-health. Retrieved September 17, 2014, from http://www.spine-health.com/conditions/degenerative-disc-disease/pain-medications-degenerative-disc-disease-treatment
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