Subjective Data
Chief Complaint (CC)
The patient is currently suffering from recurring back pains and is using hydrocodone bitartrate to relieve the pain
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.
Medications
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
Childhood: None
Adult: Cervical Cancer, Recurrent Back Pains
Ob/Gyn: pregnancy x3, no complications, 3 living adult children
Psychiatric: none
Hospitalizations/Surgeries: hysterectomy 2014, underwent transfusion. Appendectomy 1985
Family History
Father β deceased, Cardiovascular Disease
Mother β alive, aged 94, None
Social History
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.
ROS
General
The patient exhibits walking abnormalities possibly due to her back pain problems.
Cardiovascular
The patient reports feeling cold in lower extremities which suggests cardiovascular pathology. Lower extremities are colder.
Skin
No rashes, bruising, bleeding, or skin discolorations, no changes in the skin are observed.
Respiratory
The patient denies shortness of breath or having trouble breathing. No coughing, wheezing, hemoptysis, or dyspnea is reported.
Eyes
The patient is short-sighted due to age and wears glasses.
Gastrointestinal
The patient denies abdominal pain, N/V/D, and constipation.
Ears
The patient denies ear pain and no hearing impairment is observed.
Genitourinary/Gynecological
The patient is past menopause, the uterus has been removed surgically. No vaginal, abdominal, leg, or chest pain is reported.
Nose/Mouth/Throat
The patient denies sinus problems, dysphagia, nose bleeds, discharge, dental disease, hoarseness, and throat pain. All healthy without discharge or mucous membranes.
Musculoskeletal
The patient reports recurring back pains and stiffness in the lower back.
Breast
SBE reveals no bumps or lesions.
Neurological
The patient reports seldom headaches, denies syncope, seizures, weakness, or paresthesia
Heme/Lymph/Endo
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.
Objective Data
Weight 185lbs.
BMI 29
Temp 96.9 degrees F
BP 164/86
Height 5β2
Pulse 68
Resp 16
General Appearance
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.
Skin
The patient is in good physical condition for her age, with healthy, if somewhat pale, skin, hair, and nails. No rashes or lesions noted.
HEENT
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.
Cardiovascular
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.
Respiratory
Symmetric chest wall. Respirations are regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal
The abdomen is symmetric, soft, and rounded. No hepatosplenomegaly is observed.
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.
Genitourinary
The bladder is non-distended; no CVA tenderness.
Musculoskeletal
The patient reports recurring back pains and stiffness in the lower back. The patient exhibits walking abnormalities possibly due to her back pain problems.
Neurological
No speech problems observed. Balance stable; reflexes and gait are normal.
Psychiatric
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.
Lab Tests
None
Special Tests
None
Differential Diagnoses and Diagnosis
Differential Diagnoses
Chronic back pain related to osteoarthritis
Chronic back pain related to inflammatory conditions
Final Diagnosis
Chronic pain related to osteoarthritis
Plan/Therapeutics
Plan
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.