Chief Complaint : “My back hurts so bad I can barely walk” History of Present Illness: A 35-year-old male painter presents

Chief Complaint
: “My back hurts so bad I can barely walk”

History of Present Illness: A 35-year-old male painter presents to your clinic with the complaint of low back pain. He recalls lifting a 5-gallon paint can and felt an immediate pull in the lower right side of his back. This happened 2 days ago and he had the weekend to rest, but after taking Motrin and using heat, he has not seen any improvement. His pain is sharp, stabbing, and he scored it as a 9 on a scale of 0 to 10.

Drug Hx: Motrin for pain.

Family Hx: Father hypertension, Mother DM
Subjective: He is having some right leg pain but no bowel or bladder changes. No numbness or tingling.

VS: temperature: 98.2°F, respiratory rate 16, heart rate 90, blood pressure 120/60 
O2 saturation 98%

General: well-developed healthy 35-year-old male; no gross deformities

 HEENT: Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries.

Lungs: CTA AP&L

Cardiac: S1S2 without rub or gallop

Breast: INSPECTION: no dimpling or abnormalities noted upon inspection

PALPATION: Left breast – no abnormalities noted. Right breast – denies tenderness, pain, no abnormalities noted.

Lymph: no bruising, fever, or swelling noted, no acute bleeding or trauma to skin.

Abd: benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.

GU: Bladder is non-distended.

Integument: intact without lesions masses or rashes.

MS: No obvious deformities, masses, or discoloration. Palpable pain noted at the right lower lumbar region. No palpable spasms. ROM limited to forward bending 10 inches from floor; able to bend side to side but had difficulty twisting and going into extension. 

Neuro: DTRs 2+ lower sensory neurology intact to light touch and patient able to toe and heel walk. Gait was stable and no limping noted.

1.
What other subjective data would you obtain?

2.
What other objective findings would you look for?

3.
What diagnostic exams do you want to order?

4.
Name 3 differential diagnoses based on this patient presenting symptoms?

5.
Give rationales for your each differential diagnosis.

6.
What teachings will you provide?

500 words, APA style, 2 academic resources

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

  Follow these guidelines when completing each component of the Collaboration Café.  Contact your course faculty if you have questions.  Include the

  Follow these guidelines when completing each component of the Collaboration Café.  Contact your course faculty if you have questions.  Include the following sections:  Application of Course Knowledge:  Answer all questions/criteria with explanations and detail: Define what person-centered care means to you.  Describe how you will apply the following principles in your future

see attached files For this assessment, you will write a 4–6 page annotated bibliography where you identify peer- reviewed publications that

see attached files For this assessment, you will write a 4–6 page annotated bibliography where you identify peer- reviewed publications that promote the use of one of the technologies presented below that enhance quality and safety standards in nursing Tele-psychiatry: Tele-psychiatry allows for the provision of psychiatric evaluation, consultation, and

see file Mental Health and Rehabilitation Centers: o Context: These centers cater to individuals with mental health issues or those undergoing

see file Mental Health and Rehabilitation Centers: o Context: These centers cater to individuals with mental health issues or those undergoing rehabilitation for substance abuse. The stigma associated with mental health and addiction makes privacy paramount. o Social Media Concern: Discussing patient progress, sharing stories, or even describing daily challenges