Introduction
The patient is a 40-year-old Asian American male working as a roofer. After lifting a heavy object three days prior to the examination, the patient got low back pain. The reported symptoms and the results of the diagnostic testing point to lumbago as a priority diagnosis.
Subjective Data
Chief complaint: low back pain radiating to the right buttock, tingling sensation in the right thigh. The patient had never undergone CT scans, X-ray scans, etc. HPI: The patient had similar pain in the past; however, the pain was not so severe. No chronic medical problems reported. About three years ago the patient went to see a chiropractor, which resulted in some relief. The patient does not do any stretching exercises and has been gaining weight over the course of the past several years. ROS: Radiating pain in the right buttock. Tingling sensation in the right thigh that goes down to the toes. No signs of gross hematuria present. The patient denies abdominal pain, nausea, vomiting, fever, pain with urination, and urinary or bowel incontinence. Medications: successful relief from Ibuprofen in the past. 800 mg. of Ibuprofen every four hours.
Objective Data
Physical examination: height – 6’, weight – 220 lb. Blood pressure: 120/78. Pulse: 92, regular. Temperature: 97. R: 18 bpm, non-labored. Regular heart rate without murmur. Clear lungs. No lymph nodes. Android obesity. Slightly diminished pulse in the extremities. Mentally alert and oriented. Decreased motor strength of the right leg, tingling sensation. Normal reflexes, cerebellar functions intact.
Testing results: urine dipstick test and complete blood count within normal limits. L5/S1 disc protrusion. Degenerative changes of lumbar vertebrae.
Assessment
Low back pain in the ICD-10 system’s code is M54.5 (ICD10Data.com, 2017). Since the pain was reported after lifting a heavy object and the patient is not of older age, the first priority diagnosis would be lumbago (ICD-10 – M54.41). It is consistent with the results of testing results and reported sensations. However, there may be more severe illnesses, since the patient already had similar complaints. Specifically, age, gender, and occupation of the patient increase the possibility of the lumbar herniated disc as a priority diagnosis (ICD-10 – M51.26). Finally, the reported numbness and the degenerative changes in the vertebrae suggest the arthritis of the spine as one of the priority diagnoses (ICD-10 – M13.88).
Plan of Care
Lumbago
The treatment should be focused on curing the acute disease since the patient did not report the issue earlier. Furthermore, the cause of the pain is most likely trauma, which does not denote any possible chronic problems. Nevertheless, the chronic nature of the pain must not be excluded.
Varma et al. (2013) provide an overview of the current practices regarding the treatment of spinal cord injuries. According to authors, some of the most potent sources of treatment medication-wise are methylprednisolone (MP), nimodipine, gacyclidine, thyrotropin-releasing hormone (TRH), and others. However, this kind of treatment is mostly focused on preventing further damage to the spinal cord. The main reason for the pain may be treated via non-pharmacological approaches.
Lumbar Herniated Disc
As stated by Ma, Chan, and Carruthers (2014), “costs associated with spinal cord injury are greatly influenced by the patient’s severity of the injury and resultant degree of disability” (p. 7). Therefore, it is necessary to provide treatment as soon as possible. The problem that doctors may face lies in the fact that the patient had the same issue before and did not report it to the clinic. This worsens the condition by adding possible developed complications, which will present a significant obstacle for both patient and medical staff to overcome. Therefore, timely treatment may not be burdened with previously formed complications.
Arthritis of the Spine
Treatment of arthritis of the spine usually focuses on the alleviation of symptoms through non-pharmacological lifestyle changes. Specifically, exercise and weight reduction are highly recommended to the patient. However, research by Boldt et al. (2014) suggests that non-pharmacological approaches are not investigated enough to state that they perform better than treatment with the use of pharmacological means.
Evaluation of Priority Diagnosis
It must be noted that the previous issues of experienced lumbar spine pain reported by the patient were relieved by the chiropractor, so the arthritis is most likely excluded, whereas lumbar herniated disc does not explain the tingling sensation. The chosen priority diagnosis is thus lumbago. The physical demands for treatment are primarily lifestyle changes whereas chief psychological demands are stress, low self-esteem, and depression. Therefore, the interdisciplinary team should include a counselor, an educator that would provide self-care assistance, and possibly an instructor for physical exercise.
Facilitation and Barriers
The main barrier to disorder management is the patient’s financial resources, low self-esteem due to divorce, and lack of family support. Therefore, the most viable strategy would be the introduction of facilitators such as encouragement from nurses and familiarizing the patient with different self-management strategies.
Conclusion
This assignment demonstrates how musculoskeletal diseases may manifest in the human body. The present example of a patient’s complaint had been analyzed. The case revealed that there might be several causes of the pain experienced by the patient. Three most possible causes were presented including their ICD-10 diagnosis codes. The plan of care mostly focused on treating the most likely cause of the pain. However, it was noted that other reasons must not be wholly excluded before implementing certain procedures. The plan of care then presented possible ways to treat the patient and what the treatment’s expenses may give to the patient.
References
Boldt, I., Eriks-Hoogland, I., Blinkhof, M. W., de Bie, R., Joggi, D., & von Elm, E. (2014). Non-pharmacological interventions for chronic pain in people with spinal cord injury. The Cochrane Database of Systematic Reviews, 11.
ICD10Data.com. (2017). ICD-10 diagnosis codes.
Ma, V. Y., Chan, L., & Carruthers, K. J. (2014). The incidence, prevalence, costs and impact on disability of common conditions requiring rehabilitation in the US: Stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain. Archives of Medical and Physical Rehabilitation, 95(5), 986-995.
Varma, A. K., Das, A., Wallace, G., Barry, J., Vertegel, A. A., Ray, S. K., & Banik, N. L. (2013). Spinal cord injury: A review of current therapy, future treatments, and basic science frontiers. Neurochemical Research, 38(5), 895-905.