Gloria Jenkins iHuman

Gloria Jenkins iHuman

Patient Demographics

Patient’s Name: Gloria Jenkins

Age: 65-years-old

Gender: female

HPI (History of Present illness):

Gloria Jenkins is a 65-year-old female who presented to the clinic with the chief complaint of back pain that started two days ago while she was working. The pain is located on her lower back and is described as sharp in character, felt deep inside her back not on the skin, and is graded as 7/10 on pain scale. The pain is present at all times (continuous) and is unaffected by bending forward or sitting. The pain makes it hard for her to sleep and worsens when she is working, on moving, rolling over in bed, and walking and standing for a long time Gloria Jenkins iHuman. She is currently unable to lift anything. The pain has no known relieving factors, and the patient has not tried any treatments for the pain. The pain radiates to the right leg, causing pain in the leg. The pain has since onset not gotten any better and the patient reports that she has never had such pain before. She denies any recent trauma or fall or anything like it. There is no associated weakness or numbness, or tingling sensation on her legs. However, she reports difficulty moving due to the pain. She denies any history of spinal disease or popping sensation heard before the onset of the pain.

Problem Statement:

Ms. Jenkins, a 65 years old female who present with the acute onset of Left Back Pain on a pain (7/10) 2 days ago following the moving of heavy tables at work. The pain starts in her back and radiates down right leg impairing both gait and her sleep. Upon PE, it shows positive straight leg raise on both right with positive finding with contralateral leg raise, RLE sensory, motor and reflex deficits. She denies fever/chills/night sweat, bladder/bowel dysfunction and denies unintentional weight loss. She has PMH of osteoporosis, 40-pack years smoking history and steroid use history. Family history of cancer and heart disease.

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Gloria Jenkins iHuman Primary Diagnosis

Herniated intervertebral disk.

The diagnosis for Ms. Jenkins is Herniated intervertebral disk. A Pt experiences herniated intervertebral disk when a part of the muscle pushes through an annulus crack. The herniated disc causes compression of nerves orth spinal cord leading to neurological deficits (motor, sensory, or reflex deficits) (Dydyk, Massa, & Mesfin, 2021). The symptoms include pain in the foot, leg, arm, or back (Fujii et al., 2019). The Pt may also feel weakness or numbness in the leg or arm and irritate nearby the nerves. The diagnosis for the Pt is Herniated intervertebral disk because she has Herniated intervertebral disk symptoms such as RLE sensory, back pain radiating on right leg, and positive straight leg raise on both R. the risk factors for herniated intervertebral disk include weight, genetics, smoking and being lifting heavy material. The patient has a 40-year pack year smoking history and she is more likely to experience herniated intervertebral disk. The disease can be managed conservatively with NSAIDs and physical therapy as the first line treatment modalities (Dydyk, Massa, & Mesfin, 2021). Other management options include epidural steroid injection and surgery for pain that is refractory to other management options.

Differential Diagnoses

Osteoporotic compression fractures

Osteoporotic compression fractures take place at the vertebral body causing the spine to collapse and weaken. The symptoms include back pain, loss of height, problems in controlling bowels and bladder, hunched over appearance. One of the symptoms for osteoporotic compression fractures possessed by the patient includes back pain. Osteoporotic compression fractures can be ruled out because the patient has no lost height and is able to control bowels and bladder. Like disc-herniation, surgery is only considered for severe debilitating symptoms of this disease.  Its management is often physiotherapy and analgesic for pain relief.

Spinal neoplasm

This refers to any malignant tumor occurring within the spine. These are the primary tumors that could occur within the spinal cord, excluding tumors of the meninges, autonomic nervous system, and peripheral nerves. However, all these neoplasms could lead to back pain, variable. Radiculopathy, and spinal cord compression syndrome. Symptoms include back pain radiating to other parts of the body, less sensitive to pain, cold and hear, loss of bladder or bowel function and difficulty walking (Din et al., 2022). The patient is experiencing back pain that radiates to the leg which is an indication of spinal neoplasm. Spinal neoplasm can be ruled out because the patient denied bowel and bladder dysfunction.

Muscular strain

The last alternative diagnosis is muscular strain. Muscular strain is an injury to tendon or muscle that connects bones to muscles. The symptoms include pain or tenderness, bruising, swelling, and muscle weakness (Urits et al., 2019). The patient has back pain but did not report swelling, and bruising.

Pharmacological Therapies

• Ibuprofen OTC 400mg PO q 4-6 h PRN for pain and inflammation. Do not exceed 2400mg/day. Take with food to avoid IG upset.
• Analgesic – Morphine sulfate intramuscular 5 mg STAT; Shift to tramadol 25 mg

tablets once daily in the morning to be taken orally for a week. Dispense 7 tables.

Consider epidural steroid injections, however it only provides short-term use.

Risk factors: 

Complete Hysterectomy, thin bones, Hypertension, asthma-steroid use

Gender: Female

Age:65

Family History: Cancer (mother) and Heart issues (father).

Social Determinants of Health

• Educate to quit smoking.

 Health Promotion:

• Education on lifestyle modification to maintain a healthy weight and better.

control of her diabetes and hypertension.

• Enrollment is appropriate hypertension or cardiovascular and smoking cessation.

programs.

• Education on better lifting mechanisms and the need to reduce straining at work.
• Encourage for adequate bed rest and rest in between shifts.

Patient education:

• Explanations and advice given to patients and family members.
• Informed the patient that the disease is often self-limiting in most patients, and that the symptoms will go away on their own within two to twelve weeks.
• Educate on physical activity and diet modification to maintain a healthy weight.
• Advised on the need to adhere to medication for better controlled BP and blood sugar levels.
• Educated to stop smoking and advised to join smoking cessation programs.
• Educate to minimize straining at work and apply good lifting body mechanics or techniques.
• Advised to ensure adequate bed rest and to take adequate rests between shifts at work.

Follow-up/Disposition

• Upon discharge, follow up with the patient in a week to reevaluate pain levels and

readjust or change medication as required to possible NSAIDs.

• Referral to the physiotherapist after three weeks for physical therapy.
• Follow -up for possible surgery if indicated.

References

Din, R. U., Cheng, X., & Yang, H. (2022). Diagnostic role of magnetic resonance imaging in          low Back pain caused by vertebral endplate degeneration. Journal of Magnetic             Resonance Imaging, 55(3), 755-771.

Dydyk, A., Massa, R., & Mesfin, F. (2021). Disk Herniation. Stat Pearls [Internet]. Treasure

Island (FL): Stat Pearls Publishing.

Fujii, K., Yamazaki, M., Kang, J. D., Risbud, M. V., Cho, S. K., Qureshi, S. A., … & Iatridis,   J. C. (2019). Discogenic back pain: literature review of definition, diagnosis, and            treatment. JBMR plus, 3(5), e10180.

Urits, I., Burshtein, A., Sharma, M., Testa, L., Gold, P. A., Orhurhu, V., … & Kaye, A. D.   (2019). Low back pain, a comprehensive review: pathophysiology, diagnosis, and       treatment. Current pain and headache reports, 23, 1-10 Gloria Jenkins iHuman.