Chief Complaint (CC)
The patient is currently suffering from recurring back pains and is using hydrocodone bitartrate to relieve the pain
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History of Present Illness (HPI)
The patient is currently suffering from recurring back pains and is using hydrocodone bitartrate to relieve the pain. The patient exhibits walking abnormalities possible due to her back pain problems. The risk of peripheral vascular disease increases dramatically with age, and the patient already reports feeling cold in lower extremities.
The patient is currently on a 500mg per day dosage of hydrocodone bitartrate – Chronic Pain
Medication Intolerances: penicillin intolerance
Past Medical History (PMH)
Allergies: Allergic to penicillin
Tobacco, alcohol, or illicit drug use in the past: The patient does not smoke and only drinks an occasional glass of wine. The patient has no ETOH or illicit drug use or history.
Chronic Illnesses/Major traumas: None reported
History of any illness
Adult: Cervical Cancer, Recurrent Back Pains
Ob/Gyn: pregnancy x3, no complications, 3 living adult children
Hospitalizations/Surgeries: hysterectomy 2014, underwent transfusion. Appendectomy 1985
Father – deceased, Cardiovascular Disease
Mother – alive, aged 94, None
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The patient is a middle-level college graduate who worked as a middle-school teacher for thirty-three years, retired at the age of fifty-eight mostly due to increasing health complications. The patient is widowed but is supported by her children and friends. The patient does not accept the fact of being subjected to home or institutional care.
The patient exhibits walking abnormalities possibly due to her back pain problems.
The patient reports feeling cold in lower extremities which suggests cardiovascular pathology. Lower extremities are colder.
No rashes, bruising, bleeding, or skin discolorations, no changes in the skin are observed.
The patient denies shortness of breath or having trouble breathing. No coughing, wheezing, hemoptysis, or dyspnea is reported.
The patient is short-sighted due to age and wears glasses.
The patient denies abdominal pain, N/V/D, and constipation.
The patient denies ear pain and no hearing impairment is observed.
The patient is past menopause, the uterus has been removed surgically. No vaginal, abdominal, leg, or chest pain is reported.
The patient denies sinus problems, dysphagia, nose bleeds, discharge, dental disease, hoarseness, and throat pain. All healthy without discharge or mucous membranes.
The patient reports recurring back pains and stiffness in the lower back.
SBE reveals no bumps or lesions.
The patient reports seldom headaches, denies syncope, seizures, weakness, or paresthesia
There is no bruising, night sweats, increased thirst/hunger, or swollen glands. Psychiatric
The patient is in good mental health. The mental state of the patient suggests that she is determined to regain her former health condition and is motivated to get healthier.
Temp 96.9 degrees F
Despite her age, the sixty-one-year-old patient is currently in a good physical condition, with no abdominal, urinary, musculoskeletal, or neurologic issues observed or reported. The patient had no major injuries and is currently cancer-free.
The patient is in good physical condition for her age, with healthy, if somewhat pale, skin, hair, and nails. No rashes or lesions noted.
Hair is distributed evenly. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. The pharynx is nonerythematous and without exudate. Teeth are in good condition.
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. The patient reports feeling cold in lower extremities which suggests cardiovascular pathology. Capillary refill time 4.5 seconds.
Symmetric chest wall. Respirations are regular and easy; lungs clear to auscultation bilaterally.
The abdomen is symmetric, soft, and rounded. No hepatosplenomegaly is observed.
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.
The bladder is non-distended; no CVA tenderness.
The patient reports recurring back pains and stiffness in the lower back. The patient exhibits walking abnormalities possibly due to her back pain problems.
No speech problems observed. Balance stable; reflexes and gait are normal.
No psychiatric issues observed or reported. The patient is aware of her surroundings, speaks clearly, and maintains eye contact. The patient denies depression but reports feeling that she retired too early.
Differential Diagnoses and Diagnosis
Chronic back pain related to osteoarthritis
Chronic back pain related to inflammatory conditions
Chronic pain related to osteoarthritis
The goal of the treatment is to provide pain relief through manual therapy in addition to prescribed analgesics and reduce factors that may attribute to it. Recurring back pains impair the physical mobility of the patient; therefore, providing optimal pain relief should be a priority.
- Step 1: Locate the source of pain, and ask the client to describe the exact characteristics, such as frequency, intensity, or severity of pain, to reduce pain and measure the outcome of the treatment.
- Step 2: Provide maximum pain relief with selected manual therapy techniques in addition to prescribed medications. Evaluate the effectiveness of these additional pain relief measures by reducing the intake of prescribed medications to reduce their side-effects. The pain level should be measured on a 0-10 scale at the beginning of treatment and compared with the measurement received at the exit.
- Step 3: Anticipate and decrease the negative effects of prescribed medications to improve the well-being of the patient.
Evaluation of patient encounter
The assessment was among the first I did as a nurse practitioner student. I helped the physician with the assessment and wrote down the patient’s answers. I joined in on the conversation regarding the patient’s experience with cancer. As a nurse practitioner, I think the biggest strength is my ability to hear and be heard. I believe in the value of communication and feedback, and I am a very supportive and respecting person, which helped during the assessment.
Nonetheless, I feel that I need to develop some attributes in my nursing role. This includes being more confident, improving my decision-making skills, and developing my authoritative voice. Depending on the situation, it might be beneficial to take control of the group and dictate what is to be done. It is also important to be more confident when making decisions regarding the diagnosis and treatment plan.