Comprehensive Patient Assessment
General Patient Information
• ML is a preparatory class teacher aged 56 years. She is of Hispanic origin, having been born and brought up by her Hispanic parents who moved to California in the early 30s. Mary is married and has two children, a son and a daughter who are in their teenage years.
• Source: the patient was her source and her reliability being fair
Current health status
• ML has been complaining of exacerbation of her back pain that has indicated an escalation within the last two weeks. Within the last few weeks, she has relied on a borrowed wheel chair to use around the house due to the pain. According to her, it starts as an aching pain that becomes sharp with a form of movement. The pain according to her gets worse if she spends long durations sitting and is normally relieved whenever she leans forward. Occasionally the pain radiates around her legs. The patient has a degenerative joint disease as well as spinal stenosis, indicating that she fell severally in her younger years, from where the pain started. The use of Lumbar x-rays and MRI in the WebCIS have indicated that there is the presence of severe spondylosis with the foraminal and central canal narrowing about the degenerative variations.
• ML has additionally reported a sore throat that has been prevalent for the past one week, with white pus in the back of her throat. The patient exhibits a mild cough producing clear sputum that has not subsided but does not have major dyspnea. The patient additionally says that the pain is mostly felt on her left side that she believes around her 8th rib space. She further says that she recorded a fever of more than 100 degrees Fahrenheit the previous week but negates any of the other constitutional symptoms as chills, night sweat or being afebrile. The ML has additionally denied having nausea, excessive fatigue, dysphagia, drooling or vomiting. ML has not taken any medication that was meant to relieve pain although she asserts that she has been improving over the past three days.
• ML had her menstrual cycle two years ago and reported that it was normal as the others that had passed. The pain in her back and sore throat has affected her sexual life over the past month; an attribute she believes has been affecting her husband also. Overall, ML asserts that she has always been satisfied with their sexual relations until the complications started emerging, making it hard uncomfortable.
• The patient is neither pregnant, and neither has she been taking oral contraceptive nor any other form of hormone therapy.
• ML has been treated for hypertension, allergic rhinitis, depression, tobacco abuse as well as diabetes mellitus 2. She has additionally been treated for GERD and colonial polyps.
• The use of Lumbar X-rays and MRI in the WebCIS have indicated that the presence of severe spondylosis along with central canal and narrowing of the foraminal due to the degenerative changes. She has been standing on a regime of methadone 40mg daily in an attempt to relieve her back pain.
• She had osteomyelitis in her second left toe, s/p amputation in 06/08/15, breast cancer 2004 s/p mastectomy and tamoxifen, left foot cellulitis exhibiting abscess from foreign body 2008 s/p and left medial malleolus fracture 2010.
• Regarding hospitalizations, ML has surgeries and procedures that involved the amputation of the left 2nd toe at disal phalanx, appendectomy in 2003, right mastectomy in 2004 and hysterectomy 2012.
• Dermotic Oil, 0.01% ear, drops bid
• Docusate Sodium 100mg prn
• Lipitor 80mg po qhs
• Neurontin 300mg, taken 900mg tid
• Mg-oxide 400mg, take 1600mg bid
• Nexium 40mg qd
• Citalopram HBR 40mg takes 1.5tabs qd
• Enalapril 2.5mg qd
• Aspirin 81mg qd
• Kenalog, 0.1% cream, applied bid
• Metformin HCl 850mg tid
• Furosemide 80mg bid
• Lidoderm, 5% patch, applied q12 hrs prn
• Wellbutrin SR 100mg bid
• Detrol LA 4mg qd
• Methadone 20mg
• The assessment of the allergies that the patient exhibits makes it apparent that she is allergic to valdecoxib, Vancomycin, and prednisone
• The details relating the maintenance of the patient’s health are not clear. The anticipation is that these records are going to be obtained from her PCP. The moment that her TTP will be treated with the follow up arranged with her PCP and additional screening is to be encouraged.
Family Medical History
• The father is MI at the age of 76, hypertension and is still alive. The mother, on the other hand, has colon cancer, diabetes, and hypertension and is still alive also. The overall assessment of her general family reveals that there have been significant cases of heart disease, stroke, and melanoma as well as breast cancer.
• The patient has been smoking for more than 25 years and is currently smokes two packets a day. She also takes alcohol three times a week.
• ML has two children, a son and a daughter who are both in their teens. She has never had any complications in giving birth, and neither has she ever miscarried.
• On the case of sexually transmitted infections, she asserts that she has previously had bacterial infections, with the worst one being herpes while she was in college. She has never contracted either hepatitis A or B viruses and her recent HIV test indicated that she was negative. She used acyclovir (Zovirax) and valacyclovir (Valtrex) in treating in herpes.
• ML’s menarches reveal that she had her last smear test in 2010 and was normal. All the subsequent smear tests have been normal. The 56-year-old patient had a last menstrual period two years ago and denied the presence of any rectal or vaginal bleeding. The assessment of a detailed comparison of her body density evaluation in 2010 against the one in 2016 indicates that there has been a slight decline in the overall bone mineral density at the hip. According to the patient, there was a mammography that was conducted three weeks ago and the results of the study indicated a normal outcome.
Personal Social History
• The patient has been living with her husband in California in an apartment with their two children. With the challenges that ML has been facing the children and her husband have been doing most of the work at home. Hispanic in the region maintains close, and the ties have been vital in the assessment of ML’s condition and seeking medical assistance. The Hispanic community in the region has even offered money assistance through contributions that are meant to assist her to seek specialized medical assistance.
• ML is a university graduate having majored in education and works as a preparatory teacher. The husband, on the other hand, is an IT specialist in of the multinational corporations in California. The although the family has not been experiencing financial difficulties, ML’s condition has made it impossible for her to work, making the husband the sole breadwinner.
• ML indicates that she has never suffered any form of abuse or forced sex from any part throughout her life. Her occupational does not exemplify any major issues that could contribute to her state of health. It, however, follows that the long durations spent supervising her students have been a constant trigger of her back pain.
• The patient asserts that she has been smoking for the greater part of her life and has been taking alcohol constantly, approximately three times a week but asserts that it has never been an issue of concern to her or the immediate family. She further does not engage in any additional exercise other than the normal works she takes in her class as well as the occasional walks around the school compound to check on her students.
• ML denies taking caffeine regularly and that she has been sleeping well before the start of the back pain. Additionally, she asserts that she checks on her diet well, ensuring that the food eaten is mostly organic and a balanced diet.
The Assessment of Systems
• The general assessment of the patient is clear that the patient denies having fatigue, chills fever and decrease in appetite. ML has been sleeping well until the back pains started when she could not sleep due to the pain in her back. She maintained a good PO intake until the previous study when started vomiting.
• Skin: the patient asserts that she does not have any rashes or lesions anywhere on her body
• HEENT: she asserts that she does not exhibit double vision, blurry vision as well as changes to her acuity. She never wears glasses
• The ears: she asserts that she has not recorded any changes top her hearing
• Assessment of the throat, nose/ mouth and teeth follows that the patient confirms to exhibit sore threat with minimal congestion although with pus at the back of her throat. She, however, denies dental pain and rhinorrhea.
• Cardiovascular- ML denies having any cases related to palpitation or chest pain. She further denies having any claudication in the lower extremities.
• Gastrointestinal: there are between 1 and three bowel movements occasioned by constipation that she relieves via the use of docusate sodium. She has not experienced any challenges that are associated with the black or bloody stool. She has additionally not experienced any form of abdominal pain or diarrhea.
• Hematopoietic: the patient indicates that she does not have any issues as excess bleeding or easy bruising.
• Genitourinary: ML indicates that she has been having intermittent urinary incontinence when she takes neurotin but has no dysuria, urgency or any increase in the frequency.
• Psychological and mental health: ML exhibits a normal affect in additional to a behavior that is normal to her stature and health situation.
• Vital signs: weights 96kg, pulse 55, temp 35.2 degrees Celsius, RR 17, 99% on RA, height 155 cm and BMI 39
• General: a pleasant, healthy looking lady with some distress as a result of her back pain has been quiet and mildly drowsy.
• Skin: the skin does not have rashes or lesions on the upper extremities, the face, chest, back or abdomen.
• Lymph nodes: there were no cervical, periauricular, axillary lymphadenectomy
• Chest: scattered wheezes were heard bilaterally with no rhonchi. The egophony produced “E” sound similarly on all the lobes
• HEENT: no sublingual or scleral icterus, with the oropharynx being clear and mucus being moist. The pupils are round, equal moreover reactive to light.
• Neurologic: sensation and motor grossly intact
• Extremities: no clubbing, cyanosis or edema
• Heart: regular rhythm and rate without murmur gallop or rub
• 06/22/16– Na 144, BUN 13, K 5.7, Cl 102, Cr 1.3, BUN/Cr 13, Est GFR 49.02, Mg 1.2, Ca 8.3, P 4.2, AST 36, ALT 37, Anion gap 12
1. The back pain: the back problem has been the major challenge for ML, with the narrowing of the spinal stenosis and foraminal due to the degenerative disease being the core cause of her situation. The alternative causes of the back pain as sprain or strain about the vertebral fracture, lumbar vertebrase, infection, neoplasm or referred pelvic pain being ruled out (Itz, et al., 2013). The assertion is that strain and sprain are accountable for almost 70% of the low back pain although the age-related degenerative changes; disc herniation and spinal stenosis are the subsequent common causes that account for almost 16% of chronic back pain (Pillastrini, et al., 2012).
a) Considering the chronic nature as well as a rate of progress of ML’s disease, degenerative changes along with stenosis and herniation are the most probable causes of the pain.
b) The prevailing attribute is that the most effective long term intervention is unclear, with the use of spinal surgery for the lumbar stenosis being fairly a well studied and the challenges considered. In this case, the fact ML has a high surgical risk due to the complications of osteomyelits, hypertension as well as advanced age; she is a poor candidate for surgery. The moderate gain that would be realized from surgery is not worth the risk of operating her.
c) Physical therapy is an additional strategy that would be beneficial to ML in the early investigations and could be adopted for ML in future.
d) The management strategy at this point will be on the controlling of the pain that ML has been experiencing. The patient has been on methadone regimen for a long time and has developed an emotional and physical reliance on the drug (Issack, et al., 2012). It is imperative that she continues taking methadone 20mg in the morning, 5gm at lunch, 10mg in the evening and 10 mg before going to bed. The management plan will encompass a careful avoidance of NSAIDs due to the possible side effects it has which include hypertension, diabetes and tobacco abuse (Olsen, et al., (2012). It is additionally necessary that she stays ambulatory with a supporting Walker allowing her to walk with some forward flexion.
• On the case of a sore throat, ML has been afebrile with the HEENT exam not being indicative of any signs of bacterial pharyngitis as exudates or tonsillar swelling. It is additionally evident that the physical exam is not indicative of pneumonia or any other infection that would warrant any form of antibiotic therapy (Balagué, Mannion, Pellisé, & Cedraschi, 2012).
• Considering the improvements she has noted along with the time course of the compliant, it is most probable that a self-limiting upper respiratory tract infection is the main cause and will not benefit from the use of pharmacotherapy. It is imperative that she contacts her healthcare specialists if symptoms as difficulty in swallowing, high fevers of challenges in breathing and worsening of the symptoms.
• The patient education in the management of the conditions will revolve around ensuring that she moves around more often. Additionally, addressing her alcohol and smoking pattern by reducing if not quitting will additionally be the issues she should take into consideration.
• The follow up care will encompass the ML reporting to the healthcare specialist for checkups on a weekly basis as well as whenever she believes that the symptoms are worsening.
Balagué, F., Mannion, A. F., Pellisé, F., & Cedraschi, C. (2012). Non-specific low back pain. The Lancet, 379(9814), 482-491.
Issack, P. S., Cunningham, M. E., Pumberger, M., Hughes, A. P., & Cammisa Jr, F. P. (2012). Degenerative lumbar spinal stenosis: evaluation and management. Journal of the American Academy of Orthopaedic Surgeons, 20(8), 527-535.
Itz, C. J., Geurts, J. W., Kleef, M. V., & Nelemans, P. (2013). Clinical course of non‐specific low back pain: A systematic review of prospective cohort studies set in primary care. European Journal of Pain, 17(1), 5-15.
Olsen, A. M. S., Fosbøl, E. L., Lindhardsen, J., Folke, F., Charlot, M., Selmer, C., ... & Hansen, P. R. (2012). Long-Term Cardiovascular Risk of Nonsteroidal Anti-Inflammatory Drug Use According to Time Passed After First-Time Myocardial Infarction A Nationwide Cohort Study. Circulation, 126(16), 1955-1963.
Pillastrini, P., Gardenghi, I., Bonetti, F., Capra, F., Guccione, A., Mugnai, R., & Violante, F. S. (2012). An updated overview of clinical guidelines for chronic low back pain management in primary care. Joint Bone Spine, 79(2), 176-185.