NURS 6512 week 8 Essay Discussion
Assessing Musculoskeletal Pain
History of Present Illness (HPI): MJ is a 42-year-old Caucasian male that presents to the office today experiencing lower back pain. He was in his usual state of health up until a month ago, when he began experiencing pain in his left lower back. The pain started at night and was not associated with any inciting activity, so he assumed it was his arthritis acting up. The pain was initially mild and crampy, but got progressively worse until this morning, when he experienced a sudden pain shooting down his left leg while getting out of bed. He denies any injuries or loss of consciousness. He describes the pain as a 4/10 at rest, and a 10/10 when he stands. It radiates down his left leg and has done this occasionally but not as bad as this am. He claims that Percocet and lying down helps relieve the pain, and that sitting, standing or acutely coughing worsens the pain. He denies a history of unsteady gait. He denies experiencing any falls. He does experience a burning sensation to his left buttock and down left leg with numbness and tingling in left foot since this am. He denies any fever, nausea or vomiting, or decreased appetite. Denies headaches, weakness, or paralysis in legs. Denies having urinary or bowel incontinence or pain and difficulty urinating. He denies experiencing any trauma acutely before the initial onset. He denies history of any health problems except arthritis. Denies family history of scoliosis.NURS 6512 week 8 Essay Discussion
Medications:
Percocet 5/325 mg one by mouth four times daily as needed for arthritic pain
Men’s One a Day vitamin one by mouth daily
Allergies: Amoxicillin- causes hives
Past Medical History (PMH):
Arthritis -diagnosed in 2014
Chicken pox as a child
Past Surgical History (PSH): None
Sexual/Reproductive History: Recently divorced one month ago and currently not sexually active. Denies history of STDs/STIs. States he did not use condoms when married, but will when he becomes sexually active again.NURS 6512 week 8 Essay Discussion
Personal/Social History: Denies using tobacco products, alcohol or illicit drugs. Walks two miles every day and lifts weights regularly at the gym up until one month ago when back pain began. States that he is a loan officer at a local bank. He lives alone with his pet dog. States he can perform his ADLs. In his spare time, he likes to travel on his motorcycle. He states that he has no children.
Immunization History: Denies having a flu and pneumonia vaccine. Tdap 2015.
Significant Family History:
The patient’s parents are alive and well. His father is 62 with no known conditions. His mother is 65 and has hypothyroidism. He has one brother who is 40 and has hypertension, and one sister who is 38 with no known conditions. He is unable to recall grandparents’ history but all are deceased.
Lifestyle: Heterosexual male, recently divorced, lives alone with pet dog. Lives in a rural gated subdivision with a low crime rate. Works as a loan officer for past 20 years with good benefits and retirement plan. States his parents and siblings are very supportive.
Review of Systems:
General: Denies recent fever, chills, or night sweats. Denies weight loss/gain
Head: Denies headaches, head injuries, syncope, dizziness or loss of consciousness
Eyes: Denies wearing glasses or contacts. Last eye exam 2015. No history of glaucoma or excessive tearing. Denies eye pain or diplopia. Denies light sensitivity, eye trauma or familial eye disease.
Ears: Denies ear pain, tinnitus, or hearing loss. Denies recent ear infections. Denies vertigo.
Nose: Denies epistaxis or smelling difficulties. Denies rhinorrhea. Denies frequent colds, obstruction, post-nasal drip or sinus pain/pressure.
Throat/Mouth: Denies hoarseness or change in voice. Denies frequent sore throats. Denies history of tonsillitis, no trouble swallowing. Last dental exam 2016. Has own teeth without dental caries or appliances. Denies bleeding gums, ulcerations, lesion or gingivitis. Denies taste change.
Neck: Denies neck pain or tenderness. Denies neck injuries. States he has full ROM of neck. Denies any neck surgeries or history of disc disease. Denies swollen glands or lymph nodes.
Breasts: Denies lumps, masses or nodules. Denies nipple discharge. Denies family history of breast cancer
Respiratory: Denies cough or hemoptysis. Denies pain with breathing. Denies dyspnea, cyanosis, wheezing or sputum production. Denies exposure to TB, unable to recall last CXR NURS 6512 week 8 Essay Discussion
Cardiovascular/Peripheral Vascular: denies chest discomfort or pain. Denies palpitations or chest tightness. Denies history of abnormal heart rhythms or murmur. Denies history of EKG or heart studies. Denies previous MI, edema, or hypertension. Denies orthopnea. Exercises daily for 30 minutes. Walks two miles every day. Denies bruising easy, blood clots, or inflammation of veins.
Gastrointestinal: Denies appetite gain/loss. Denies intolerance to foods. Denies dysphagia, heartburn, nausea, vomiting or hematemesis. States bowels move regularly every day. Denies constipation or diarrhea. Denies change in stool color or contents. Denies flatulence, hemorrhoids, hepatitis or jaundice. Denies dark urine. Denies history of gastric ulcers, gallstones, polyps or tumors. Denies sigmoidoscopy or colonoscopy
Genitourinary: denies dysuria, flank or suprapubic pain. Denies urgency, frequency, nocturia, hematuria, polyuria or hesitancy. Denies decreased urinary output. Denies edema to face. Denies stress incontinence or history of hernias. Denies discharge from penis.
Musculoskeletal: States history of arthritis since 2014. Denies history of gout, trauma or fractures. Denies joint swelling or redness. States limited ROM for past month in back. Reports back pain with radiation down left leg. Reports not being able to exercise or walk his daily two miles due to pain.
Psychiatric: denies history of depression, suicidal or homicidal ideations. States that he has occasionally felt “a little blue” since his divorce. Denies mood changes or difficulty concentrating. Denies nervousness or tension. Denies irritability or sleep difficulties
Neurological: denies syncope, seizures, or tremors. States he has numbness and tingling in left foot since this am. Denies weakness or paralysis. Denies recent falls or abnormal movements. States burning sensation in left buttock down left leg past knee
Skin:denies rashes, itching or bruising. Denies history of skin cancer or lesions. Denies use of tanning bed. Denies clubbing or cyanosis of nails.
Hematologic: Denies history of blood transfusions, clotting disorders or easing bruising. Denies anemia history.
Endocrine: Denies thyroid enlargement or tenderness. Denies heat or cold intolerance. Denies unexplained weight gain/loss, denies polydipsia, polyuria. Denies change in facial or body hair. Denies increased hat or glove size. Denies skin dryness or cracking.
Allergic/Immunologic: Denies frequent infections or recent infections. Denies HIV/AIDs or any STDs. He is allergic to amoxicillin which causes hives.NURS 6512 week 8 Essay Discussion
OBJECTIVE DATA:
Physical Exam:
Vital signs: T 98.4 oral, HR 75 and regular, R 19 and unlabored, BP 170/88 manual, sitting, left arm. Right arm, manual, sitting 168/86. 02 sat 96% RA. Height 6’0, Weight 180. BMI: 24.4
General: MJ is a well-developed white male appearing his stated age, in no respiratory distress, sitting in chair. He is alert and cooperative with the exam.
Head: Normocephalic, atraumatic. Midline of shoulders, facial features symmetrical. Scalp moves freely with no depressions, nodules or masses. No nits, parasites, or scales. No facial edema or puffiness noted. Bilateral temporal arteries 2+ without bruits or tenderness.
Eyes: Visual acuity 20/20 Snellen chart. Peripheral vision intact. EOMI. No orbital edema, sagging or puffiness. Conjunctivae clear, no exudate or hemorrhages noted. Eyelids symmetrical without redness or flakiness, fasciculation’s or ptosis. Eyebrows symmetrical and extend past eyes bilaterally. Corneal light reflex intact. No nystagmus noted. Red reflex present. Optic disc creamy pink with sharp, well defined margins. Retina reddish-pink without vascularization’s. No neovascularization’s hemorrhages or microaneurysms noted. No AV nicking.
Ears: Auricles symmetrical bilaterally without pain or tenderness. Otoscope exam reveals minimal cerumen, no lesions, discharge or foreign bodies. Tympanic membranes are pearly grey with bony landmarks and light reflex visualized bilaterally. No bulging or retractions noted. No fluid or air bubbles visualized. Whisper, Rinne and Weber intact.
Nose: Symmetrical, nares patent bilaterally. No discharge, crusting, flaring or polyps noted. Turbinate’s pink, septum midline without perforation. No sinus tenderness or swelling noted. CN I intact.
Throat/Mouth: All teeth present and intact. No missing or chipped teeth. No dental appliances. Lips are pink and symmetrical, smooth without lesions or nodules. Tongue beefy red and symmetrical without crusting. Oral mucosa pink and moist. No nodules or lesions noted in buccal pouch. Oropharynx has no lesions or exudate. Tonsils grade II without redness, edema, or exudate.
Neck: Supple, full ROM. Thyroid moves freely with swallow test. No nodules or masses palpated. No lymphadenopathy. Trachea midline. No carotid bruits noted. No JVD. JVP 6 cm at 45-degree elevation. No webbing or skinfolds noted.
Chest: Breathing appears non-labored and symmetrical. No accessory muscles, cyanosis or nostril flaring noted. Thumbs diverge symmetrically with thoracic expansion. Respiratory excursion 4 cm bilaterally. No pain or tenderness noted over ribs or bony prominences. No pain or tenderness noted when palpating breasts. No swollen axillary lymph nodes.
Lungs: Respiration 19 and unlabored. Appears quiet and at ease. Vesicular breath sounds noted all lung fields. No adventitious sounds. Resonance heard over all lung fields with percussion. Tactile fremitus symmetrical. No cough or stridor noted. No friction rubs. No egophony, bronchophony.
Heart: Point of maximal impulse is noted in the fifth intercostal space midclavicular line. Regular rate and rhythm. S1 and S2 normal. No S3 or S4. No murmurs noted. No heaves or lifts. Capillary refill <2 seconds all extremities. Nails without clubbing or cyanosis. NURS 6512 week 8 Essay Discussion
Peripheral Vascular: Carotid pulses, radial pulses, tibial pulses and pedal pulses all palpable and rated a 2+. No bilateral peripheral edema noted. No lesions, sores or open wounds noted to bilateral feet.
Abdomen: Nondistended, no tenderness to palpation. Bowel sounds present all four quadrants. No masses were palpable. The liver span percussed to 9cm. No hepatomegaly or splenomegaly noted. No renal artery bruits auscultated. No hernias palpated. Negative McBurney’s point.
Genital/Rectal: Penis and testicles without lesions. No inguinal hernias are present. Rectal exam had intact tone. Firm, symmetric, nontender prostate without nodules.
Musculoskeletal: Spine vertically aligned. Normal S-curvature. No nodules, masses, or tenderness with palpation. Full ROM in all joints. BUE and BLE symmetrical. No pain or tenderness with palpation of joints. Extremities symmetrical in length, circumference, alignment, and position. Muscle size symmetrical without atrophy or hypertrophy. No pain or tenderness with passive ROM. Active and passive ROM equal between contralateral joints. No crepitation’s or tenderness with movement noted. Thoracic spine convex. Lumbar spine convex. Knees and feet in proper alignment. Cervical spine concave with head erect in appropriate position. Skin folds symmetrical.NURS 6512 week 8 Essay Discussion