NU 665B Week 11 Assignment 1: Comprehensive Case Study

Sample Answer for NU 665B Week 11 Assignment 1: Comprehensive Case Study

Your Medical Assistant Has Given You the Following Information

A 59-year-old female presents with complaints of fatigue and low back pain x2 days. 

The MA completed vital signs per protocol.

Vital Signs

• Temp: 97.9
• Respiratory Rate: 18
• Blood Pressures / Heart Rate:

• 112/78
• 68
• Pain: 9/10​

You are getting ready to see the patient.

What are you going to do first?

Before seeing the patient, I will take time and review her history, past medical history, surgical history, family history, personal, social & economic history, and gynecological history. I will also review her other medical records as that will form a basis of understanding and knowing the patient better. According to Flugelman (2021), this information helps to understand the patient’s genetic predisposition to specific conditions, risk factors, drug allergies, intolerance, and adverse drug reactions, support systems, lifestyle, and socio-economic status, which can impact present symptoms and management options. In regard to preventive care, this information will help to understand whether the patient is uptodate with annual recommendations for health maintenance including the patient’s healthcare preferences, unique circumstances, and concerns with the aim of providing patient-centered care.

Before going into the patient’s room, I ensure all needed equipment is ready. Then, I wash my hands well, following hygiene rules. Once I enter, I introduce myself politely to the patient, creating a friendly and respectful atmosphere.

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Subjective history lesson: can you tell me about your:

Medical History – menopause at age 52

Surgical History –none

Social History – The patient lives with her husband and takes no medication. She currently works as a nurse at a level 2 trauma center in the PCU. She denies ETOH or smoking.

Family History

• Mother – alive at age 75; hypothyroidism
• Father – alive at age 79; hypertension
• Brother –age 55; non known

Additional Information

She reports having difficulty standing upright and must change position frequently when sitting or lying down. She denies any specific incident that preceded the pain; she states it just started as stiffness but has progressively worsened. When asked about pain radiation, the patient confirms that pain is radiating down to her mid-thighs, bilaterally. The patient reports that her activities are limited by the pain despite the use of acetaminophen, ibuprofen, and ice. She also says she’s been a little more tired lately. 

Please dictate your Patient Problem List

• Low back pain (pain with an acute onset, severity 9/10)
• Difficulty standing upright

• Fatigue
• Pain radiates bilaterally to mid-thighs.
• Pain interferes with her QoL (quality of life), limits movement and activities despite medication and ice application.
• Stiffness

Subjective history lesson: can you tell me about you.

Medications

• Black cohosh daily
• MVI daily

After reviewing the history and medication list, what findings are you concerned about as her provider?

• Upon examining the patient’s symptoms, medication list, and medical history, it’s important to consider excluding cauda equina syndrome as a potential diagnosis. This condition necessitates immediate attention because postponing treatment could result in long-term disability. Symptoms may appear suddenly or develop slowly, including pain, numbness, or weakness in one or both legs. An immediate MRI is essential to rule out cauda equina syndrome. (Epocrates, 2024).
• Considering the patient’s complaint of low back pain and fatigue, I am concerned whether her present symptoms are related to her occupation, family history (thyroid disorder) or interactions between her current medications. As a result, the complaint about fatigue may necessitate further investigation into causes such as thyroid dysfunction, anemia or medication-related side effects (Hektor et al., 2023).
• Pain management – the patient informs that she has used several pain managements medications: ibuprofen, acetaminophen and ice with no relief. She further rates her pain severity as 9/10. This clearly demonstrates that the pain is severe, it negatively impacts her QoL (quality of life) and it cannot be solely controlled with OTC medications. Therefore, she needs a more comprehensive assessment of the pain with considerations for alternative management strategies (Hektor et al., 2023).
•  Daily multivitamin – I am concerned about the contents in her multivitamin and the duration that she has been taking it. While generally considered beneficial and safe, I am interested to know whether it has any ingredients that can have negative interactions with other drugs or high doses of minerals/vitamins that can cause adverse effects when consumed in excess (Hektor et al., 2023).
• Black cohosh – commonly known for its use in the management of menopausal symptoms, black cohosh has also been linked to causing potential hepatotoxicity (Mohapatra et al., 2022). Therefore, I am concerned about the duration she will take black cohosh and close monitoring for liver dysfunction.

Please provide a list of three differential diagnoses with rationale for the back pain for the 59-year-old patient.

As mentioned before, cauda equina syndrome is the primary condition that needs to be ruled out initially, but it’s also important to consider these additional differential diagnoses.

• Lumbar Radiculopathy (Sciatica) – the patient’s description of the pain is characteristic of sciatica which refers to a pain syndrome resulting from lumbar spine nerve root irritation or compression. It can be due to spinal vertebra degeneration, herniation of the lumbar disc, or spinal stenosis (Casazza, 2012). Patients with menopause-related osteoporosis are at a higher risk. Patients always describe the pain as acute onset, dull ache, severe, with a mild tingling or burning sensation, radiating to the mid-thigh or feet (Casazza, 2012). Although it’s mostly unilateral, it can be bilateral and gradually worsens with activity, movement, straining, coughing, sneezing, or laughing.
• Muscle strain or sprain – the patient at menopause, she is 59-years old and  currently a nurse at a level 2 trauma center in the PCU hence, she is engaged in activities that involve frequent lifting, bending, and cause physical exertion. According to Casazza (2012), this increases her overall risk of musculoskeletal injuries such as a muscle sprain and strain. The worsening pain with activity and movement further support this diagnosis.
• Degenerative Disc Disease (DDD) – has a direct correlation with advancing patient’s age. According to Casazza. (2012), it is primarily characterized by gradual degeneration of the spinal intervertebral discs and additional risk factors for this patient are a menopausal history and advanced age (59-years old). Patients often report of a lower back pain radiating to the lower extremities and buttocks and worsens with prolonged standing, sitting, or movement.

Please provide a list of three differential diagnoses with rationale for fatigue for the 59-year-old patient.

• Iron deficiency anemia (IDA) – in IDA, there is a decrease in hemoglobin levels which may result from decreased iron absorption, insufficient intake of iron, or blood loss (Maisel, Baum & Donner-Banzhoff, 2021).  In menopausal women, IDA anemia may result from malabsorption. Although mostly asymptomatic, patients often report symptoms such as decreased ability to work, fatigue, shortness of breath (SOB), or dizziness.
• Thyroid dysfunction – particularly hypothyroidism, thyroid disorders can result in lethargy, fatigue, and generalized weakness. This patient’s mother has a PMH of hypothyroidism which increases the patient’s genetic risk of hypothyroidism. Besides, the hormonal changes that occur during the transition to menopause can affect the functioning of the thyroid prompting the onset of a thyroid disorder (Maisel, Baum & Donner-Banzhoff, 2021). To evaluate for thyroid dysfunction, the patient will have to undergo additional tests; free thyroxine (T4), and thyroid stimulating hormone (TSH).
• Medication-related side effect – the patient currently uses multivitamin supplements and black cohosh which can directly or indirectly cause fatigue through drug-drug physiological interactions (Maisel, Baum & Donner-Banzhoff, 2021).

PHYSICAL EXAM

What additional objective information would be useful or is missing from this exam based on the patient’s subjective complaints?

During the physical examination, assessing her thyroid gland to check for size, shape, tenderness, or nodules would be important, especially given her family history of hypothyroidism (Hektor et al., 2023).

Muscle strength – information about the muscle strength in each on the lower extremities is missing. This information is essential in localizing the source of the pain, extent of musculoskeletal dysfunction and the potential nerve involved (Hektor et al., 2023).

Gait and balance – it is important to note and the patient’s gait and balance to identify potential functional impairment caused by the lower back pain. This also includes any guarding behavior, or compensatory movement when walking to understand the impact and severity on the patient’s everyday life (Hektor et al., 2023).

A neurological evaluation using light touch or pinprick tests can help identify symptoms of nerve compression or radiculopathy (Hektor et al., 2023).

Inspection of the back for signs of deformity, skin lesions, or signs of inflammation (Hektor et al., 2023).

Psychosocial Evaluation

The patient seems surprised when you begin asking questions about her psychosocial status. Why is psychosocial evaluation important for patients with low back pain?

Generally, a psychosocial evaluation helps to evaluate the multidimensional nature of the patient’s pain, including the risk factors and to develop a more personalized management approach that addresses holistic aspects of care.

• Vulnerability – there exists evidence on the co-occurrence of pain with psychiatric illnesses such as anxiety disorders, depressive disorders, and personality disorders. As highlighted by Mescouto et al., (2022), a psycho-social evaluation will help to identify an existing co-occurrence which can inform interventions including behavioral, lifestyle, and medications.
• Pain is subjective – individuals form pain-specific beliefs which define how they understand and interpret pain and influence their utilization of healthcare (Mescouto et al., 2022). These beliefs can further influence a patient’s response and adherence to treatment.
• Support systems & coping strategies – a psychosocial evaluation will provide a comprehensive understanding on the resources available for the patient (social support) and coping mechanisms during recovery (Mescouto et al., 2022). Patients with strong support systems are adequately equipped to adhere to treatment and manage their pain and vice versa.
• Lifestyle and Health behavior – there is a direct correlation between psychosocial factors that impact lifestyle and health behavior. A perfect example is poor sleep routines and nutrition which can interfere with recovery. According to Mescouto et al., (2022), evaluating these factors is crucial in addressing the modifiable risk factors that impact the patient’s pain and providing support during management.
• Ability to work – it is important to understand the level of impact of the pain on the patient’s ability to work and perform ADLs. The patient’s responsibilities involve repetitive movements; lifting, prolonged sitting, and standing which further increase her overall risk of musculoskeletal injuries. This analysis helps to further identify other ergonomic issues to guide interventions that promote recovery and prevent further injury.  This also includes decisions on whether or not the patient needs time away from work and the most recommended duration to promote recovery (Hektor et al., 2023).

X-RAY

To warrant an order for an x-ray (radiograph) for acute low back pain (ALBP), what conditions should exist?

• Fever exceeding 38°C (100.4°F) for more than 48 hours.
  • Cauda equina syndrome symptoms (Epocrates, 2024).
  • Loss of bladder or bowel control (incontinence or retention) (Hektor et al., 2023).
  • Pain associated with leg weakness or distal numbness (Hektor et al., 2023).
  • Progressive neuromotor deficits (Hektor et al., 2023).
  • History of suspicion of malignancy (Hektor et al., 2023).
  • Significant trauma (Hektor et al., 2023).
  • Osteoporosis (Hektor et al., 2023).
  • Clinical suspicion of ankylosing spondylitis (Hektor et al., 2023).
  • Unrelenting pain at rest or night pain (Hektor et al., 2023).
  • Progressive weight loss (Hektor et al., 2023).
  • Chronic use of oral steroids (Hektor et al., 2023).
  • Use of immunosuppressive medications/ immunosuppressed patient (Epocrates, 2024).

PATIENT PLAN

What is your plan for this patient?

Pharmacological

• Cyclobenzaprine 5 mg, take 1 Tab by mouth every 8 hours for low back pain for 14 days (Casazza, 2012).
• Ibuprofen 800mg 12hourly PO daily PRN for 7 days to manage moderate back pain. Take with food

Non-pharmacological

• Encourage the patient to maintain a healthy weight and BMI through lifestyle modification involving regular physical activity and a healthy diet
• For muscle strengthening, flexibility, gait, and posture, recommend physical therapy with targeted exercises (Casazza, 2012).
• Encourage the patient to gradually integrate low-impact activities in her everyday life as she recovers. These activities include yoga, swimming, regular walks, stretches, and sit-ups (Casazza, 2012).
• Consider cognitive behavioral therapy (CBT) and mindfulness-based therapy for stress management.
• Recommend workplace ergonomic modification to decrease lower back strain

Labs (Hektor et al., 2023)

• Thyroid stimulating hormone (TSH) – to evaluate for thyroid dysfunction.
• Free thyroxine (T4) – to evaluate for thyroid dysfunction.
• Complete blood count with differentials – to evaluate for anemia.
• Ferritin level
• Serum folate
• Vit B12

Diagnostics

• Lumbar spine x-ray to assess for spinal abnormalities, disc herniation, and degenerative spine changes (Hektor et al., 2023).

Referrals

• Refer the patient to a physical therapist for further pain management and close monitoring involving directed home and stabilization exercises (Casazza, 2012).
• If the patient demonstrates no improvement with currently prescribed pain management strategies, she will be referred to a pain management specialist for further evaluation and management. This will also include referral to an orthopedic specialist for further evaluation of potential underlying musculoskeletal disorders (Hektor et al., 2023).

Follow-up

• To return for follow-up in 14 days to evaluate progress, review imaging and laboratory results and modify the management as needed.
• To return immediately or visit the emergency room if you develop sudden onset loss of bladder/bowel control/retention, fever, distal numbness/leg weakness.
• If the pain worsens or persists despite taking the prescribed medications, return immediately or visit the emergency room.

Patient Education and Instructions

What will you include in patient education and instructions?

• I will include in the patient’s education an overview of what ALBP is, its most common causes and its natural history while offering reassurance on how most episodes resolve spontaneously without the need for aggressive management (Hektor et al., 2023).
• Generally, NSAIDs are the first-line agents for therapy and since the patient informs that both acetaminophen and ibuprofen haven’t been effective for pain relief, prescribe a muscle relaxant together with ibuprofen (Hektor et al., 2023).
• I will emphasize my recommendation of physical therapy for muscle strength, flexibility, and stabilization (Hektor et al., 2023).
• I will encourage cold and heat therapy, acupuncture, and massages for muscle discomfort and stiffness (Hektor et al., 2023).
• I will include danger signs (red flags) that indicate an underlying issue which warrants immediate medical intervention; loss of bowel/bladder control, fever, leg weakness, distal numbness, unintentional weight loss, and worsening pain (Hektor et al., 2023).
• Currently, I will recommend avoidance of high-impact activities which strain the lower back or worsen the pain such as prolonged standing, sitting, and heavy lifting while encourage light low-impact exercises and activities to promote mobility, stability, and flexibility (Hektor et al., 2023).
• Make sure vaccines UTD (Hektor et al., 2023).

References

Casazza, B. A. (2012). Diagnosis and treatment of acute low back pain. American family physician, 85(4), 343-350.

Flugelman, M. Y. (2021). History-taking revisited: Simple techniques to foster patient collaboration, improve data attainment, and establish trust with the patient. GMS Journal for Medical Education, 38(6). https://doi.org/10.3205%2Fzma001505

Hektor, D. L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2023a). Primary care: The art and science of advanced practice nursing – an interprofessional approach. F.A. Davis.

Eposrates. Cauda equina syndrome – Symptoms, Causes, Images, and Treatment Options. (n.d.). https://www.epocrates.com/online/diseases/3000164/cauda-equina-syndrome.

Maisel, P., Baum, E., & Donner-Banzhoff, N. (2021). Fatigue as the chief complaint: epidemiology, causes, diagnosis, and treatment. Deutsches Ärzteblatt International, 118(33-34), 566. https://doi.org/10.3238%2Farztebl.m2021.0192

Mescouto, K., Olson, R. E., Hodges, P. W., & Setchell, J. (2022). A critical review of the biopsychosocial model of low back pain care: time for a new approach?. Disability and Rehabilitation, 44(13), 3270-3284. https://doi.org/10.1080/09638288.2020.1851783

Mohapatra, S., Iqubal, A., Ansari, M. J., Jan, B., Zahiruddin, S., Mirza, M. A., & Iqbal, Z. (2022). Benefits of black cohosh (Cimicifuga racemosa) for women health: An up-close and in-depth review. Pharmaceuticals, 15(3), 278. https://doi.org/10.3390/ph15030278