Analyze the disorder addressing the following elements: pathophysiology, signs/symptoms, progression trajectory, diagnostic testing, and treatment options. Differentiate the disorder from normal development.
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Criteria:
Case Study Evaluation
Analyze the disorder addressing the
following elements: pathophysiology, signs/symptoms, progression trajectory,
diagnostic testing, and treatment options.
Differentiate the disorder from
normal development.
Discuss the physical and
psychological demands the disorder places on the patient and family.
Explain the key concepts that must
be shared with the patient and family to achieve optimal disorder management
and outcomes.
Identify key interdisciplinary team
personnel needed and how this team will provide care to achieve optimal
disorder management and outcomes.
Interpret facilitators and barriers
to optimal disorder management and outcomes.
Describe strategies to overcome the
identified barriers.
Care Plan Synthesis
Designed a comprehensive and
holistic recognition and planning for the disorder.
Addresses how the patient’s
socio-cultural background can potentially impact optimal management and
outcomes.
Demonstrated an evidence-based
approach to address key issues identified in the case study.
Formulates a comprehensive but
tailored approach to disorder management.
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. 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
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 fo rhelp. 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 from 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.
Vital Signs: Ht: 6'; Wt: 220; WC: 40; BP:
120/78; T: 97 po; P: 92 and regular; R: 18 nonlabored
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.
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