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1 page/≈275 words
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Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Case Study
Language:
English (U.S.)
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Topic:

Assessing Musculoskeletal Pain

Case Study Instructions:

Advance health assessment NURS 6512
Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case
A case study.
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
Please apply two citations. Thank you

Case Study Sample Content Preview:
General Information:Patients Name: XXX
Age: 42 y/o Sex: MaleDate of Birth: XX
Address: XX
Civil Status: SingleHandedness: RightOccupation: Bank Accountant Religion: XX
Citizenship: XX
Referring Doctor: XXRehab Doctor: XX
Date of Referral: May 8, XX
Date of Consultation: XX
Date of IE: XX
Date Start of RehabXX
Dx: Myofascial Pain Syndrome (MPS)
Subjective:
PT translation: “My back and left have been hurting. The pain worsens every time I move my back towards the left.” Patient Goal: PT translation: “To get rid of the pain on my back and leg for me to be able to do the things I used to do.”
HPI
The present condition started on May 7, 2020, while the PT worked as an accountant at a bank. PT stated he started feeling discomfort and slight pain at his ® upper back and at the back of his ® neck as well with p/s 5/10. PT stated that the pain began to worsen throughout the day as PT’s job requires him to sit, count money, and type on the computer all day. PT described the pain as dull and aching p/s 7/10. PT would massage the affected area in hopes of alleviating the pain but to no avail. As soon as he arrived home, PT stated he applied an ice pack on his ® upper back and ® neck to help ease the pain. PT stated the pain was momentarily relieved with p/s 6/10. PT stated he rested for the rest of the night and avoided moving his back.
PT went to seek a consult at XXXX Hospital and was attended by Dr. KKKKK on May 8, 2020. The Dr. prescribed Advil 500 mg and Flexeril 5mg (see present medications) to the PT. In addition, PT was asked to undergo an X-ray on his ® lower back and leg (see ancillary procedures). As a result, PT was diagnosed with myofascial ...
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