Paper Example on eBill: 57-Year-Old African American Construction Worker Struggling with Back Pain

Introduction

Bill is a 57-year-old male African American who is a construction worker. He drives a dirt mover that has tires about 7 feet high. It makes the ground rumble when the engine is turned on. Bill says he gets "shaken up" all day when he's working. He presents complaining of back pain after five straight days of work. He is unable to stand upright and leans forward when walking. He says that standing is more comfortable than sitting. He has been taking some of his girlfriend's "muscle relaxers" and says they help him. He is divorced but has a significant other who shares a home with him. He states he used to take Lisinopril 20 mg q day for high blood pressure, but quit when his prescription expired about 11 months ago.

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Medications:

Lisinopril 10mg daily

Past medical history (PMH):

Used to take Lisinopril 20 mg q day for high blood pressure, but quit when his prescription expired about 11 months ago.

Sexual/reproductive history:

He has noted some erectile dysfunction (ED) but is sure it is from his hectic work schedule and long hours.

Personal/social history:

Bill is a tobacco smoker. He admits to smoking 1 ppd for the past 20 years. He also has a 6 pack of beer every "couple of days" to help him "relax" after work. He states he has "cut back" from a 6 pack a day when his GF told him he was gaining too much weight.

Immunization history:

Can't recall the last immunization he had, "possibly in high school."

Significant family history:

He is divorced but has a significant other who shares a home with him.

Lifestyle:

He is a construction worker. He drives a dirt mover that has tires about 7 feet high. He also has a 6 pack of beer every "couple of days" to help him "relax" after work. He states he has "cut back" from a 6 pack a day when his GF told him he was gaining too much weight. He admitted to some difficulty passing urine in the past 3 months but states there is no blood or foul odor to the urine.

Review of Systems:

General: back pain after 5 straight days of work + inability to stand upright + some erectile dysfunction+ weight gain

HEENT: No changes in vision or hearing; he does wear glasses. He reported no history of glaucoma, diplopia, floaters, excessive tearing, or photophobia. He has had no recent ear infections, tinnitus, or discharge from the ears. He does not have a history of nasal polyps or recent sinus infection. His dentition is poor, and he has reddened puffy gums. There are several missing and broken teeth in the lower posterior right and left mandible.

Back: He complains of back pain after 5 straight days of work.

Respiratory: no difficulty breathing at rest.

Leg Muscles: Pain when the leg is elevated

CV: No chest discomfort, palpitations, history of murmur, no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication.

GI: No nausea or vomiting, reflux controlled. No abdominal pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation.

GU: Some difficulty passing urine in the past 3 months, but states there is no blood or foul odor to the urine. No history of STDs or HPV. He noted some Erectile Dysfunction (ED)

MS: He has no arthralgia/myalgia, no arthritis, gout, or limitation in his range of motion by the report. No history of trauma or fractures.

Psych: No history of anxiety or depression. No sleep disturbance, delusions, or mental health history.

OBJECTIVE DATA

Physical Exam:

Vital signs: Ht 72 inches, wt 298, B/P 162/90, HR 84 regular, respirations 20 and SPO2 is 97%

General: A&O x3, NAD, appears mildly uncomfortable

HEENT: PERRLA, EOMI, oronasopharynx is clear

Neck: Carotids no bruit, jvd or lymphadenopathy

Chest/Lungs: CTA AP&L except crackles LLL

Heart/Peripheral Vascular: RRR without a murmur, rub, or gallop; pulses+2 bilat pedal and +2 radial

ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness - diffuse - no rebound

Musculoskeletal: symmetric muscle development - some age-related atrophy; muscle strengths 5/5 all groups

Neuro: CN II - XII grossly intact, DTR's intact

Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes

ASSESSMENT:

Lab Tests and Results:

Diagnostics:

Lab: CBC - WBC 18,000 with left shift

Radiology: Left lower lobe consolidation

CXR - cardiomegaly with air trapping and increased AP diameter

ECG - normal sinus rhythm

Differential Diagnosis (DDx):

Acute Viral Bronchitis - pt with cough and fever, history of smoking. Does have elevated WBC with left shift, so makes this diagnosis less likely. (Globe et al., 2008).

Pulmonary Embolus - pt with cough, smoking history, and chest pain with coughing. Because pt also has a fever, and normal pulse ox, makes this diagnosis less likely.

Lung Cancer - although this pt is at high risk for lung cancer due to the lengthy history of smoking, the cxr does not reveal any nodules.

Diagnoses/Client Problems:

CAP Left lower lobe - the severity of illness score (CURB-65) less than 2 (Licciardone et al., 2012).

COPD

HTN controlled Licciardone

Tobacco abuse - 40-pack-a-year history

GERD - quiet, on no current medication (Pearce et al., 2016)

PLAN:

Start patient on ibuprofen (800mg 3x per day) for 10 days to ease the back pain. To continue on regular exercise and should return to the clinic if symptoms persist. Smoking cessation education is given. Pt is also due for mammogram and routine labs. Will order total cholesterol, TSH, CMP, CBC, fasting blood sugar, UA to be done at 2 weeks follow up visit. Pt needs to be fasting. Also will schedule routine mammogram and colonoscopy in the next two months.

Reflection: the facts that Bill's pain was noted to radiate from the back to the lower leg due to prolonged sittings were significant red flags for sciatica. This condition is characterized by pain spreading from the back to the buttocks and the legs. Sciatica relates to the herniated disc that impinges on the nerves, especially at the levels of L5-S1. The pain that results from such nerve impingement could be aggravated by sneezing and prolonged sitting. The straight leg test revealed the occurrence of some pain. Since the patient describes the pain as being dull, it could be related to the radiculopathy, which is characterized by some sharp burning pain in the back that spreads to the legs. I learned a lot from this patient this week. I was not familiar with the assessment tool CURB-65. I now realize how important this tool is to help decide whether or not the patient needs to be admitted to the hospital or not. Although this patient was sick at the time of her physical, we still addressed risk factors and reviewed medications. Since the patient is sick at this time, we decided to pursue other labs at her follow up visit. This particular patient does have a history of compliance, other than continuing to smoke, so we felt comfortable with her treatment.

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References

Globe, G. A., Morris, C. E., Whalen, W. M., Farabaugh, R. J., & Hawk, C. (2008). Chiropractic management of low back disorders: a report from a consensus process. Journal of manipulative and physiological therapeutics, 31(9), 651-658.

Licciardone, J. C., Gatchel, R. J., Kearns, C. M., & Minotti, D. E. (2012). Depression, somatization, and somatic dysfunction in patients with nonspecific chronic low back pain: results from the OSTEOPATHIC Trial. The Journal of the American Osteopathic Association, 112(12), 783-791.

Licciardone, J. C., Kearns, C. M., Hodge, L. M., & Minotti, D. E. (2013). Osteopathic manual treatment in patients with diabetes mellitus and comorbid chronic low back pain: subgroup results from the OSTEOPATHIC Trial. The Journal of the American Osteopathic Association, 113(6), 468-478.

Pearce, P. F., Ferguson, L. A., George, G. S., & Langford, C. A. (2016). The essential SOAP note in an EHR age. The Nurse Practitioner, 41(2), 29-36.