nsg6001 w5

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South University, Savannah *

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6001

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Medicine

Date

Jan 9, 2024

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docx

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2

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Discuss the Mr. Payne’s history that would be pertinent to his genitourinary problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know. Mr. Payne presents with complaints of lower back pain (LBP), 2 weeks in duration, pain is sharp and stabbing. The onset of pain was after carrying 10lb box, resolved on it’s own but returned after exertion (playing softball). HPI: pain in lower back unspecified side. Started 2 weeks prior, relieved on its own but reemerged after exertion, does not radiate. Described as sharp and stabbing. Patient is a truck driver, sits for long periods and lifts boxes at work. No recent trauma. Social & family: former smoker 20 years 1ppd, quit 2 years ago. Occasional ETOH use, no substance abuse. One intimate partner diagnosed with HIV. PmHx: Hypertension, Hyperlipidemia Describe the physical exam and diagnostic tools to be used for Mr. Payne. Are there any additional you would have liked to be included that were not?  The physical exam will include full vital signs, visual assessment of the back and palpation. Assessing for any abnormalities to spine, rashes, or lumps. Assess gait for difficulty walking. Additionally, include in assessment a discussion regarding urinary habits. Given the patient is a truck driver Lower back pain can be a symptom of urinary tract infections that have progressed to the kidneys (Lo Basso, et al., 2021). At this time no laboratory or imaging workup is warranted due to patient not having symptoms that raise flags for infection, malignancy or recent trauma. Please list 3 differential diagnoses for Mr. Payne and explain why you chose them.  What was your final diagnosis and how did you make the determination? - Pyelonephritis, this can be a result from a UTI that was left untreated and traveled to kidneys. May cause symptoms of low back pain. - Muscle strain, this can be resulting after carrying the 10lb box the patient mentioned. Improper lifting techniques can lead to muscle strain. - Sciatica, this diagnoses arose after patient mentioned having pain that travels from lower back to left ankle. What plan of care will Mr. Payne be given at this visit, include drug therapy and treatments; what is the patient education and follow-up? Mr. Payne should remain active within his normal activities, no need to rest in bed. Muscle relaxants or NSAIDs can be ordered for pain as needed. Since Mr. Payne has been using NSAIDs regularly it would be appropriate to order muscle relaxants, non-narcotics. Since Mr. Payne is a truck driver it is important to educate him on avoiding driving with certain medications as it can cause drowsiness. When able, to relieve pain heat wraps can be utilized as well as.
Lo Basso, F., Pilzer, A., Ferrero, G., Fiz, F., Fabbro, E., Oliva, D., Cazzarolli, C., & Turrina, A. (2021). Manual treatment for kidney mobility and symptoms in women with nonspecific low back pain and urinary infections. Journal of osteopathic medicine , 121 (5), 489–497. https://doi.org/10.1515/jom-2020- 0288
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