I need help with a response to the discussion below Discuss the Mr….

Question Answered step-by-step I need help with a response to the discussion below Discuss the Mr…. I need help with a response to the discussion belowDiscuss 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 is a 45-year-old man who is married with two daughters and drives trucks for a living. His job requires him to lift 30-45 pounds for about four hours daily. Chief Complaint: He presents today with “severe low back pain that made it difficult to get out of bed this morning” HPI: Patient complains of pain that has been ongoing for two weeks and radiates down left leg after lifting a 10-pound box. His pain is worse with sitting and improves with supine position, along with Ibuprofen, Naproxen and ice. Patient has no history of trauma, no fever/chills, no urinary symptoms and no bowel or bladder incontinence. He reports a history of intermittent low back pain that is generally resolved in 2-3 days with NSAIDS. “He complains that this level of pain is the worst he has ever had”. PMH: Patient has a hx of well-controlled diabetes and fairly controlled hypertension and hyperlipidemia. Social History: He quit smoking two years ago and reports drinking 1 to 2 beers occasionally on the weekends. Patient denies history of IV drug use. He denies any past surgical history.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 consisted of a head-to-toe examination, with focus on the musculoskeletal system. The examination included a visual assessment of the back’s contour and curvature with functionality tests, including ROM and limitation testing. All appropriate diagnostics were performed in this case study. Some of the diagnostic tests that are used in the assessment for lumbar pain include complete blood count to assess for any infections and/or the presence of an inflammatory reaction. A lumbar spine X ray due to the previous history of back trauma and the most definitive test for his lumbar pain would include an MRI to further assess for disc herniations, nerve impingements or determining if there is an old vs. new fracture.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?Herniated Disc- Pain radiating down the leg and numbness. Patient has pain radiating down his left leg.Degenerative Arthritis- The pain is worse with movement and sitting. Patient presents with repetitive strain and lifting on the job.Spinal Stenosis- Pain that improves with the supine position. Aging, lifting and trauma exacerbate stenosis of the spinal canal.         The final diagnosis was a disc herniation in the lumbar region, affecting areas L5-S1. This determination was based on symptoms and MRI, showing an inflammatory the protrusion of the intervertebral disk from its usual location.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?           The patient’s plan of care includes symptomatic treatment and could benefit from a referral to an Interventional Radiologist. Treatment of symptoms may include nonpharmacological interventions like exercise and stretching, which is helpful with radiculopathy and low back pain. The patient could also benefit from some physical therapy for strengthening of the lumbar spine. Pharmacological interventions include NSAIDS to reduce inflammation and pain, as well as muscle relaxers to reduce muscular spasms and pain. Additionally, the patient should keep a journal of his symptoms and when they occur, as well as be reassessed for a response to treatment (Dunphy et al., 2019).ReferencesDunphy, L., Winland-Brown, J., Porter, B. O., & Thomas, D. (2019). Primary care: Art and Science of Advanced Practice Nursing- An Interprofessional Approach (5th ed.). Philadelphia, PA: F.A. Davis. ISBN: 9780803667181. Health Science Science Nursing Share QuestionEmailCopy link Comments (0)