Mastering in nursing Advance Nurse Practice 1 . DQ
WK #5 DQ:
Apply instruction from the Aquifer Case Study to confutation the subjoined argument questions:
· Discuss the Mr. Payne’s truth that would be fit to his genitourinary amount. Apprehend primary repining, HPI, Social, Family and Spent medical truth that would be leading to perceive.
· Describe the substantial exam and cue tools to be used for Mr. Payne. Are there any joined you would own beloved to be sparing that were not?
· Please catalogue 3 differential diagnoses for Mr. Payne and disentangled-up why you chose them. What was your decisive singularity and how did you construct the satisfaction?
· What scheme of afflictions achieve Mr. Payne be abandoned at this scrutinize, apprehend offal therapy and tenors; what is the unrepining advice and follow-up?
Forty-five-year-old colorless courageous exchange driver fastidious of two weeks of harsh, stabbing end affliction. The affliction was reform behind a couple of days but then got worse behind munificent softball delay his daughter. This dawning his affliction is so bad that he had anxiety getting out of bed.
You and Dr. Lee follow a few minutes to retrospect Mr. Payne's chart:
· Temperature: 98.6° Fahrenheit
· Heart rate: 80 beats/minute
· Respiratory rate: 12 breaths/minute
· Blood pressure: 130/82 mmHg
· Weight: 170 pounds
· Body Mass Index: 24 kg/m2
Past Medical History: Diabetes, polite inferior. Hypertension, open coerce. Hyperlipidemia, open coerce.
Past Surgical History: None
Social History: Works as a exchange driver, which involves lifting 20-35 lbs 4 hours of the day, married delay 2 daughters,
Habits: Quit smoking two years ago, drinks 1 to 2 beers rarely on the weekends, no truth of IV offal use.
· metformin 500mg 2 twice daily
· glyburide 5mg 2 twice daily
· amlodipine 2.5 mg daily
· lisinopril 40 mg daily
· simavastin 40 mg daily
Allergies: No perceiven offal allergies.
Can you discern me environing your end affliction?"
"As I told the nurse, the affliction afloat two weeks ago behind I lifted a box at production. Equitable separate, I got this harsh affliction on the left face of my end. The box wasn't well-balanced that slow.
"I chated to the nurse at production; she said to ice it and to follow ibuprofen. It got reform behind three days. But, I was munificent softball delay my daughter definite weekend, and the affliction came end. This date it was worse than precedently. This week, the affliction is so bad I can scarcely get out of bed. I get a harsh affliction in my end which goes down my left leg to my ankle."
"On a flake of 0 to 10, 10 being the pound, how cruel is the affliction?"
"It's probably a 7."
"Have you plant alwaysything that improves the affliction?"
"Ibuprofen and Naproxen productioned at original, but they are not promotive abundant anymore."
"What environing positions that construct things reform or worse?"
"The affliction is worse delay any move of my end or sitting for a desire date. It is reform when I lie down."
"Have you had end affliction precedently?"
"Yes, I own end affliction from date to date. But I'm usually reform behind 2 to 3 days. This is the pound affliction I own always had."
Review of Systems
Mr. Payne does not own persuadeousness or frailty in his legs. The affliction is reform when he lies down. He denies urinary quantity, dysuria, amounts delay bowel or bladder coerce, falways or chills, abomination or vomiting, or gravity waste. He denies any unfair trauma, bar for when he lifted a 10-pound box at production. He denies pitiless shade affliction.
Based on your differential, you individualize that it is greatly slight that Mr. Payne is experiencing a unreflective origin of end affliction delay firmness involvement such as a disc herniation. It is practicable that he has spinal disconnector, but a delaydrawal of trauma truth constructs the perishing unreasonable. It is leading to deliberate cauda equina syndrome, as it persuades for contiguous surgical inquiry, but it is unslight in the omission of neurological symptoms affect waste of bowel or bladder coerce. Finally, infectious etiology, such as pyelonephritis, is unslight delayout falways and chills, urinary quantity and dysuria.
Back Exam - Standing:
Mr. Payne has orderly bend, softness on palpation on the left lumbar paraspinous muscle delay acception temper. Bountiful ramble of disturbance, but has affliction delay move. His remove is orderly. He can tramp on his heels and toes. He can do subterranean flexure bends.
Back Exam - Seated:
Mr. Payne denies sentiment affliction when checked for CVA softness. He has no affliction in his equitable leg delay the qualified statement of SLR. While he does not evince a penny tripod indication, he does burden of affliction when his left leg is influential. Mr. Payne's reflexes are 2+ and similar at the flexures and 1+ at twain ankles. The motor exam reveals no frailty of the muscles of the inferior extremities. His sensory exam is orderly.
Pulmonary Exam: His lungs are disentangled.
Cardiovascular Exam: His cardiac exam demonstrates a orderly rhythm, no whisper or gallop.
Three weeks posterior, Mr. Payne repays for his follow-up provision and you detect the subjoined:
Mr. Payne has had trivial alleviation delay the tenor prescribed. He is frustrated that he has been in affliction for spent than a month. His affliction has been progressively worse. It radiates down the posterioral part-among-among of his left leg and face of his left pedestal. This affliction is worse than the end affliction. He does not own any amounts delay bowel or bladder coerce and there is no frailty of his leg.
Pertinent Exam Findings
Vital indications: stable
Neurologic: Normal remove, but moves sloth due to affliction; ramble of disturbance is bountiful, delay affliction on flexion; SLR is enacted at 45 rate on the left; motor force intact; reflexes 2+ bilaterally at the flexures, listless at the left ankle, 1+ at the equitable ankle.
Dr. Lee agrees delay your singularity of radiculopathy of S1 firmness radicle delay gradation. She signal an MRI and sets up an provision to see Mr. Payne behind the MRI.
You and Dr. Lee now repay to Mr. Payne's exam extent to chat environing tenor options delay him. Dr. Lee discerns Mr. Payne to relinquish vigorous activities but to endure erratic. Dr. Lee acceptions the dosage of naproxen to 500 mg BID to follow delay living. Since his affliction is strenuous (7/10), he is abandoned a order for acetaminophen delay codeine to follow at shade, when his affliction is cruel. Mr. Payne declines a muscle relaxant beorigin they usually construct him stupid. He would affect to be referred to substantial therapy as it was beneficial in the spent.
One week posterior, Mr. Payne repays for follow-up. You retrospect the results of the MRI repute.
1. Moderate-size, herniated disc at L5-S1 delay associated notable impact on the left S1 firmness radicle and gentle to sparing impact on the equitable S1 firmness radicle. There is gentle convenient canal stenosis.
2. Annular shatter delay a little convenient disc herniation at L4-5 causing gentle convenient canal stenosis.
You retrospect the findings delay Dr. Lee. She agrees delay your singularity of radiculopathy of S1 firmness radicle due to a catholic herniated disc at L5-S1.
You persuade Mr. Payne two weeks posterior to see how he is doing. He reputes that he is doing perfectly a bit reform. He went to an osteopathic physician who did some manual therapy and afloat him on a rigorous tramping program. He is very encouraged and schemes on losing gravity through employment and viands.