Assignent Solutionnurs

RESPONSE 1:
A 38-year old male construction worker complains of severe pain to his right lower back. States he woke up with the pain after an especially difficult work day.
I would begin by asking the patient questions in an open manner, watching for any verbal or physical reactions to the questions.  These would include questions regarding the patient’s chief complaint and his medical history.
What is your pain on a scale of 0 to 10?
Describe your pain – it is aching, dull, sharp, or shooting?
Is the pain constant or episodical?
Is the pain aggravated by movement?
Is the pain relieved by rest?
Do you have any other symptoms such as fever?
Is the pain radiating to any other body part such as legs?
Have you injured your back or spine?
Do you have any bruising?
Has the pain interfered with your sleep?
Is the pain affecting your ability to work?
Have you used any medications?
SOAP FORMAT
SUBJECTIVE:
HPI:  A 38-year-old male presents with a complaint of lower back pain on his right side.  He stated that the back pain had started suddenly when he woke up this morning and was getting out of bed and had continued constantly since then. He stated that the characteristics includes a dull, achy pain, that is shooting pain upon movement and tenderness in the lower back. He rated the pain as an 8 on a scale of 0 to 10 when he moves.  Aggravating factors include sudden movements that cause shooting pain. Relieving factors includes rest and avoiding sudden movements. The patient stated that he had taken two Tylenol 500mg for the pain this morning and that it had not been effective.  He states that the pain is severe with movement.
PMH:  Patient denies any significant medical history. 
Have you been diagnosed with any medical conditions?
Have you ever had back pain previously?
Have you had any urinary problems?
MEDS:  Patient stated that he does not take any prescription medications.
Do you take any prescriptions medications?
Do you take over-the-counter medications?
Do you take any supplements?
ALLERGIES:  Patient denies any allergies.
Are you allergic to any medications?
Do you have any environmental allergies?
Does your family have any allergies to medications?
FAMILY HISTORY:
Does anyone in your family have a history of back pain?
Does your mother or father have any medical conditions?
Do you have any siblings? Do they have any medical conditions?
SOCIAL HISTORY:
Do you smoke?
Do you drink alcohol?
Do you use recreational drugs?
HEALTH RELATED:
What do you do for a living?
Is the pain affecting your sleep?
Do you exercise regularly?
Do you eat healthy at most meals?
REVIEW OF SYMPTOMS:
General:  Patient is alert and oriented x4, and he states that he is in pain this morning.  He states he had a hard day at work yesterday and woke up to severe lower right-sided pain.  He is dressed appropriately for his age, and he is well-groomed. He reports that he has not been able to control his pain and he is grimacing as he is talking to me. He denies any other symptoms.
Cardiac:  Patient denies any chest pain, irregular heartbeats, rapid heart rates, or health palpitations.
GI – Patient states he has a loss of appetite due to the pain. He denies any abdominal pain, nausea, or vomiting. heartburn, vomiting, and blood in stools.
GU – Patients denies any pain during urination, any blood in the urine, and any urgency.
Musculoskeletal – Patient states that he has severe right lower back pain of an 8 on a scale of 0 to 10, and tenderness. He denies any joint pain, shoulder pain, swelling of joints, numbness, and deformities.
Respiratory:  Patient denies any shortness of breath, night sweats, wheezing or coughing.
Psychiatric:  Patient denies any depression, anxiety, suicidal, or hearing voices.  Patient denies any insomnia.
I would then perform vital signs and perform a physical examination.
OBJECTIVE: Patient is a 38-year-old male, data from vital signs, and physical examination including examination of patient’s back.
Vital Signs:  Blood pressure: 155/90
Pulse: 90
Respirations: 18
Oxygen: 95% (Room Air)
Temperature: 97.8
Weight:  182 lbs
Height:  71 inches
BMI:  25.4
General:  Patient is Alert and Oriented x4. He is well developed. He is dressed casually and appears stated age.  He appears in acute distress but can meet my eyes as he answers my questions.
Cardiac: Heart rate and rhythm are normal.  S1 and S2 are heard, and no murmurs, gallops, or rubs are auscultated.  No S3 or S4 heard.  Chest is normal in appearance with no lifts, heaves, or thrills.
Respiratory: Chest is symmetric and without deformity.  No signs of respiratory distress.  Lungs sounds are clear in all lobes bilaterally without rales, rhonchi, or wheezing.  Resonance is normal upon percussion of all lung fields.
Abdominal: Abdomen is flat, symmetric, and non-tender without distention. There are no visible lesions or scars. Bowel sounds are present and normoactive in all four quadrants. No masses, hepatomegaly, or splenomegaly are noted.
Spine: Neck and back are without deformity, external skin changes, or signs of trauma.  Curvature of the cervical, thoracic, and lumbar spine are within normal limits. Tenderness is noted in the right lower back. Posture is slumped, gait is antalgic and patient has decreased range of motion.
Extremities: Upper and lower extremities are atraumatic in appearance without tenderness or deformity. No swelling or erythema. Decreased range of motion in right leg. Pulses palpable. Gait is antalgic and unsteady.
Neurological: The patient is awake, alert and oriented to person, place, and time with normal speech. Motor function is normal with muscle strength 5/5 bilaterally to upper and lower extremities. Sensation is intact bilaterally. Reflexes 2+ bilaterally. Memory is normal and thought process is intact.
Psychiatric: Appropriate mood and affect noted.  Good judgement and insight.  No suicidal ideation.
ASSESSMENT:  Acute lower back injury – S39.92XA
Patient presents with severe lower back pain in the right lower quadrant. He states pain level of an 8 on a scale of 0 to 10.  He has decreased range of motion and antalgic and unsteady. The pain started upon waking up and has been constant today.  “Acute strains can be caused by one event, such as using poor body mechanics to lift something heavy” (Mayo Clinic, 2020).  Patient stated the pain started upon awaking after a difficult workday.  “Low back pain is the most common occupational injury reported, and so knowing a patient’s occupation helps assess specific risk factors” (Dains, Baumann, & Scheibel, 2015).
Pertinent Positives – Pertinent positives include pain, tenderness, and decreased motion (Mayo Clinic, 2020).
Pertinent Negatives – Bruising and swelling. (Mayo Clinic, 2020).
Differential diagnosis 1 – Urinary Tract Infection
Pertinent positives – Lower back pain (CDC, 2021)
Pertinent negatives – Painful urination, pressure in the groin, blood in the urine (CDC, 2021).
Differential diagnosis 2 – Kidney Stone.
Pertinent positives – Pain in the lower back (Cleveland Clinic, 2021)
Pertinent negatives – Nausea, vomiting, pain during urination, chills, fever (Cleveland Clinic, 2021).
PLAN:  The provider will perform a physical exam of the patient including the back, spine, abdomen, and extremities looking for any tenderness, and bruising.  Patients’ back and spine were examined, and he did not have any bruising, or swelling.  He was noted to have lower right sided back tenderness. “During the physical exam, your doctor will check for swelling and points of tenderness. The location and intensity of your pain can help determine the extent and nature of the damage” (Mayo Clinic, 2020).  He is diagnosed with an acute lower back injury. Treatment includes for the patient to use the R.I.C.E. approach.  He should rest his injury, avoiding any activities that cause pain.  He should apply an ice pack every two or three hours during waking hours for approximately 15 to 20 minutes at each time.  Compression will help to keep the area from swelling. Educate the patient not to wrap the area too tightly, and to discontinue the compression if it increases the pain. Elevate the area to help reduce swelling if it occurs. The patient can take Tylenol as needed and may need a referral to physical therapy (Mayo Clinic, 2020).
The patient would be educated regular exercise and stretching can help prevent muscle strains (Mayo Clinic, 2020).  Patient will need to return if symptoms do not improve, become worse, or he develops new symptoms. He should return in two weeks for a follow-up.  If the symptoms do not improve, the patient may need an ultrasound for further evaluation. (Mayo Clinic, 2020). 
RESPONSE 2:
Topic 3:
A 58-year old obese man complains of pain in his left knee. The pain seems to be unrelenting, he says it is better when he rests, but gets stiff when he rests too long.
This is a 58 Y/O overweight male who presents with progressively worse sharp left knee pain. The pain is localized to the left knee. He denies any injury and it has been processing for the last few weeks. The pain is relieved with rest but is aggravated with attempting to weight bear after prolonged resting.
Pertinent Positive: knee pain worsening after long periods of rest. Patient states it gets “stiff”. Obesity.
Pertinent Negative: No injury. No additional medical problems.
Questions:
Have you had this pain before?
When did the pain start?
Did you injure the knee?
What does the pain feel like?
What do you take to help with the pain?
Is there a history of Rheumatoid Arthritis in your family?
When was the last time you saw a healthcare provider for the pain?
Does the pain affect both knees or just one?
Do you have any other symptoms?
Is the knee swollen?
PMH: denies
Allergies: denies
SOC: denies tobacco, etoh, drug use
CONSTITUTIONAL: Denies weight loss, fever and chills.
HEENT: Denies changes in vision and hearing.
RESPIRATORY: Denies SOB and cough.

CV: Denies palpitations and CP. 

GI: Denies abdominal pain, nausea, vomiting and diarrhea.

GU: Denies dysuria and urinary frequency.

MSK: Denies myalgia. + Left knee pain
SKIN: Denies rash and pruritus.
NEUROLOGICAL: Denies headache and syncope.

PSYCHIATRIC: Denies recent changes in mood. Denies anxiety and depression. Denies suicidal ideation, homicidal ideation.
Vitals:
BP 136/72
HR 90
RR 19
O2 98%
Temp: 98.5
GENERAL: Alert and oriented x 3. No acute distress. Well-nourished.
EYES: EOMI. Anicteric.
HENT: Moist mucous membranes. No scleral icterus. No cervical lymphadenopathy.
LUNGS: Clear to auscultation bilaterally. No accessory muscle use.

CARDIOVASCULAR: Regular rate and rhythm. No murmur. No JVD.

ABDOMEN: Soft, non-tender and non-distended. No palpable masses.

EXTREMITIES: No edema. Non-tender. Limited ROM of left knee.

SKIN: No rashes or lesions. Warm.
NEUROLOGIC: No focal neurological deficits. CN II-XII grossly intact, but not individually tested.

PSYCHIATRIC: Cooperative. Appropriate mood and affect.
Dx: Arthritis
Differential:
Chondromalacia
Patellofemoral pain (Gaitonde et al., 2019).
Gout
X-ray left knee – to view the cartilage between the distal femoral and tibia/fibula. Positive arthritis of the left knee will show a loss of cartilage space leading to increased pain with ambulation and stiffness (Ebell, 2018).
CMP, CBC, ESR, CRP, Uric Acid – ESR and CRP are inflammatory markers that will be elevated for arthritis. Uric Acid level will be used to rule out gout (Gaitonde et al., 2019).
Referral to physical therapy for aquatic therapy to improve muscle around the knee to help with ambulation and decrease stress from regular running and walking (Ebell, 2018).
Referral to Orthopedic specialist- for further evaluation and treatment as this process can take a long time. Patients may also benefit from Corticosteroid injections and possible knee replacement if conservative treatment fails.
Medication: Piroxicam 20mg take 1 tab PO once daily PRN knee pain
Education on weight loss and using a heat pad for pain in the morning to decrease stiffness of the knee. Patients may benefit from a hot shower in the morning to help with joint stiffness. Additionally, a knee immobilizer may be beneficial to increase support and provide stability for patients to decrease risks of falls (Ebell, 2018).