Chief Complaint: “I Have Been Having Lower Back Pain For Past 2 Weeks”

Adult Episodic

The patient has been experiencing lower back pain for the last two weeks. Initially, the level of the pain was small, equivalent like a pitch at the back, and it was on one point. At this time, the chief complaint could doing his normal duties with ease. In addition, the pain was recurrent in such a way that the patient could feel it at some times in the day and in others, he could not feel pain at all. However, after three days, the pain started to be worse during the night, to such an extent that the patient could have insomnia r poor sleep patterns, and occasional during the day. At some point, the patient argued that the pain used to be extreme at night since it was the only time that he was relaxing after have a busy day in the workplace, and could not feel it during the day since he was too busy to concentrate on the pain. After one week, the pain continued to be extreme to such an extent that he could not manage to perform tasks that calls for the bending of his back, such as climbing stairs. At this time, the patient was advised by his peers to try to buy painkillers one the counter and ensure he takes two tablets at bedtime. Though he managed to get sleep at taking the painkillers, the pain did not end with this. Instead, the patient started much pain on his lower back during the morning hours, to such an extent that he could forego to attend to his daily economic activities and instead opted to sleep. After two weeks, the pain elevated to extreme levels since the patient was not only unable to attend to his daily economic activities, but also performing his personal activities such as cooking or putting on clothes and shoes. At night, he could be heard groaning out of pain, especially when he undertakes any activities that require bending of his back. Precisely, the pain level at first was approximately a 4/10 on the Visual Analogue Scale (VAS), then increased to a 6/10 and finally to 10/10 when it was at its worst.

Doctor of Nursing Practitioner Role

There are numerous roles that a doctor of nursing practitioner (DNP) is entitled to undertake in the health care profession. For example, the DNP has the role of contemplating and respecting the complementary abilities, skills, and roles of the inter-professional health team. He or she ought to foster or strengthen the teamwork culture by urging the other inter-professional health care workers to embrace the aspect of implementing various health care roles as a team. In addition, the DNP has the role of successfully collaborating with the other health professionals in order to enhance the health status of groups or health care consumers as well as providing an overview of frameworks of inter-professional collaboration in real world settings. In addition, the DNP is also supposed to comprehend systems and organizational collaboration, team processes, communication and leadership, as well as coming up with innovative strategies that are aimed at improving healthcare and health of patients (Chism, 2010). Consecutively, the DNP is also supposed to share organizational leadership and decision making with the other health care stakeholders in order to best meet the needs of the population or patients. Moreover, the DNP has the role of promoting psychological safety within the health care facility by recommending resources as well as providing effective leadership. Additionally, the DNP has the role of embracing mechanisms that foster communication within the inter-professional team setting. Additionally, it is the role of the DNP to articulate to the policy makers, health insurers, and the public concerning the role that nurses play in as far as promoting positive family and patient outcomes are concerned.

Identifying Information

The patient is a 43-year African American male who visited the health care facility after experiencing severe lower back pain for a period of two weeks. The patient was accompanied by his elder son since he could not have managed to walk all the way by himself due to the severity of his condition. The patient resides on the South West of the health facility, a distance of approximately six kilometers. The severity of the pain on his lower back part had increased to the extent that the patient could not only have managed to attended to his daily activities, but also perform personal duties such as walking long distances by himself, cooking or doing general cleaning in his apartment. In addition, the patient lives himself in an apartment that is close to his workplace while his family resides in the upcountry.

Setting: Type of Specialty or Family Health

Our health care facility offers outpatient health care services since it does not have adequate resources to accommodate in-patient health services. The facility manages to attend to patients who are suffering from minor health care conditions such as chronic diseases, first aid services, maternal health care, immunization, family health, family planning, and counselling services. In case of acute and serious health conditions, the management of this facility refers patients to a nearby health care facility which is more equipped to address such cases.

Reason for Encounter

The chief complaint visited the outpatient health care facility following the worsening of his health condition. Precisely, the patient had been having lower back pain for the last two weeks, and the situation had been worsening as days goes by. During the initial days, the pain manifested itself as a small pitch on the back muscles but it elevated to deep pain that limited the patient to not only fail to attend his daily working activities, but also his personal activities. Precisely, the patient reported to have extreme difficulties in executing tasks such as getting in and out of the car, moving sit from or to stand, cleaning his apartment, and moving around his bed. In addition, the patient had difficulties in descending or ascending stairs, bending over to pick up objects, driving his car for any longer than 20 minutes, and walking for any longer than 10-20 minutes. In addition, the patient reported that the pain started at one point at his back, and it has been extending to the lower parts as days goes by. In addition, the patient also reported that the pain has not only being extending around the lower back part, but has also the level of pain has also been increasing.

History of the Presenting Illness

The patient is a 43-year old African American male who visited the health care facility for the first time after worsening of his health condition. The patient had been complaining of lower back pain for the last two weeks and could not remember falling on his back or performing duties which could have strained his back. However, the patient occupation is driving a truck that conveys farm produce from one of the agricultural plantation to the airport where they are exported to the international markets. The patient remembers one day last year, when he woke up late for work, and had to speed up his daily operations in order to ensure that the produce reaches to the airport on time, failure to which the produce would miss the intended flight. In order to catch up with time, he helped two of his workmates to load the produce in the collection center, as well as offloading the same at the airport. Though he had little back pain in the consecutive days, it was not serious since he managed to work normally, especially after taking some painkillers. Additionally, the chief complaint also revealed that he regularly takes alcohol especially during the weekends when he is not at work. Apparently, he has never consumed more than what he can withstand. In addition, the chief complain does not remember any time he has ever fallen while drunk, and this makes him to highly doubt that the back pain that he has been experiencing for the last two weeks is as a result of alcoholism.

However, apart from the lower back pains the chief complaint reported no other significant orthopedic issues. However, he has a history of depression, anxiety, and depression, and the only surgical procedure that he has ever gone through was the removal of his wisdom teeth. Prior to his lower back pains, the patient reports that he was independent in all his ADLs (activities of daily living) and was always very active not only in his work, but also in exercise related activities. However, since the start of the lower back pains, the patient had been relying on his son in terms of the execution of some personal duties such as cooking, climbing stairs and putting on clothes or shoes.

ICD Code

The ICD-10 codes are mostly used for pain management. In this case, the ICD code is M545, which is the one that is used to code low back pain (Buck, 2018). Lower back pain entails a disorder that involves the muscle and bones of the back. The lower back pain is classified based on the duration of the acute pain (lasting for less than 6 weeks) sub-chronic (if the lower back pain lasts between 6-12 weeks) and chronic (if the back pain lasts for more than 12 weeks). In this case, the lower back pain is acute since the patient had been experiencing the pain for the last two weeks (less than 6 weeks). Additionally, the lower back pain is also classified based on the underlying cause as referred pain, non-mechanical pain, or mechanical pain.

Medications

Though the patient had not visited another health facility before, he had initially made a decision of seeking medications to ease his lower back pain. At the time he visited out health care facility, he had a packet of aspirins that he had heavily relied on as the major medication of reducing the pain at his back. According to him, he visited a local chemist some days ago in an effort to seek intervention of his condition and it is at that point that he was advised to take some painkillers. Considering that he had earlier on used painkillers to relief various forms of pain such as headache and toothache, he accepted the prescription, paid, and returned to his house hoping for the best. In addition to this, the patient was also using herbal medications especially after the ambitions of the painkiller to relieve pain became futile. Some of the herbal medications that he uses were not limited to the use of capsaicin and ginger. Capsaicin is a herbal medication that is obtained from hot Chile peppers, and it tends to be important or effective in relieving pain, and it works by depleting substance P, which a compound that transfers the pain sensational from the peripheral to the central nervous system. On the other hand, ginger contains phytochemicals, and these are the aspects which make it important in relieving muscle and joint pain.

Physical Examination

Based on the physical examination, the chief complainant has significant limitation in functional mobility, strength, and endurance. Moreover, the physical examination of the patient also shows that when the latter is in a seated position, he was presented with a posterior sway. In addition, while standing, the chief complaint posture clearly shows an increased lumbar lordosis, and a slight forward head. In addition, the patient showed a moderate loss of cadence, as well as a limited motion at the hips during ambulation. Moreover, in every couple of steps that the chief complaint made, facial grimacing was evident, and this is a clear indication of the level of pain that the patient was going through. When palpation is done, there was an elevated level of tightness in the bilateral lumbar paraspinals, latissimus dorsi, and gluteals (Yoon, Lee & Kim, 2013). Moreover, the chief complaint was tender to the touch and with a moderate pressure that ranged from approximately T10-S1, posterior-superior iliac spines (PSISs), bilateral lumbar paraspinals, and latissimus dorsi.

In addition, the patient had some swellings especially at the joints, and this includes thinking of the underlying structures as well as body enlargement or atrophy of the underlying tissues. Moreover, the examiner`s thumbnail of the chief complainant was purely white.

Review of Systems

In order to review various biological systems, a number of tests were conducted. In addition, the musculoskeletal review also shows that the patient`s shoulders and elbows had a minimal loss of internal rotation. Some of the tests that were conducted are summarized in the table below.

Table 1: The musculoskeletal system

Plan of Care

The patient can recover from the lower back pains over a span of 8-24 weeks, especially if an appropriate plan of care is implemented to the letter. Precisely, through an effective plan of care, the chief complaint will demonstrate a optimal motor functioning, joint mobility, range of motion, muscle performance and the highest level of functioning at work, home, community and leisure environments. In this case, an effective plan of care entails various aspects which are not limited to gait training, therapeutic activity, therapeutic exercise, posture training, and modalities as needed. The table below shows some of the physical therapeutic goals.

Table 2: Physical therapeutic goals

Each therapy session in this plan will last between 45-75 minutes, and the patient will be made aware of any of the risks that might be associated with it, and his consent concerning his acceptance to participate in the session will be sought before every session commences. The first session will start with the patient warming up on the NuStep for approximatelt 15 minutes, and this will be done at a low resistance setting. However, this warm up is associated with some risks and this includes the patient having some difficulties when it comes to standing up. This will be followed by a low or core back stabilization exercises such as lower truck rotation, bridging, and straight leg raises, which the patient might be having difficulties to perform especially due to the lower back pains. This will be followed by a soft tissue massage to the lumber paraspinals and the bilateral gluteals, and this will help in alleviating some symptoms.

In the second session, the patient will also commence it with warming up of on the NuStep. This will be followed by simple exercises, which will be done careful in order to prevent overstressing of the tissue. Examples of these exercises will not be limited to mini clams (side lying hip abduction with the feet touching) as well as mini squats.

Diagnosis

After thorough examination, the patient was diagnosed with lumbar arthropathy which is stimulated by arthritis. The patient is having arthritis though it is in the early stages. As he grows older, the severity of this health condition could worsen, it could have been challenging to manage the condition when it is in the advanced levels, especially if the patient delays to seek medical attention. It is worth noting that one of the risk factors for this health condition is old age, as well as performing strenuous activities.

Referrals

Despite the treatment and management of the health condition that the patient received from our health care facility, the patient will also be required to seek advanced care in a more advanced health care facility, especially a facility that offers both inpatient and outpatient health care services. In a more advanced health care facility, the patient will manage to receive advanced treatment including ultra sound or ex-rays for the lower back pain and at the joints, as well as the medications for the health condition. In addition, referrals will also be made if the lower back pain that the client is currently experiencing fails to reduce at the end of the therapy period. In some cases, the patient may be referred to a more advance health care facility in order for the patient to undergo surgery.

Health Education

I will educate this patient not to go for medications for the lower back pain over the counter since he may end up worsening his health condition rather than making things better. In addition, drugs which are sold over the counter may not have the necessary prescription from a qualified health practitioner, and this means that he may end up taking overdose or under-dose of the same, and this may result to disastrous health conditions or even drug dependence. In addition, I will advise the patient to adhere to the exercise program especially while at home in order to reduce the severity of his health condition (Hidalgo et al., 2014). In most cases, patients fail to adhere with the prescribed exercise health program especially if they feel that they are experiencing pain while doing it. In contrast, the regular physical exercises help in enhancing the back flexibility as well as strengthening of the muscles that supports the back (Dagenais & Haldeman, 2012). However, it is worth noting that that at the start of the physical exercises after a new episode of low back pain may temporarily increase the pain, adhering to the prescribed physical exercise may not only prevent recurrent episodes, but also minimize the total duration of pain. In addition, I will also advise the patient to avoid strenuous activities such as carrying heavy loads on their shoulders. Moreover, I will advise the client to embrace massage and yoga schedules besides the prescribed physical exercises. Massage and yoga schedules helps in enhancing relaxation and meditation, which as a result helps in the reduction of mindfulness based stress.

Follow-ups

Though the patient is treated for his lower back pain, the health care facilities do conduct regular follow ups in order to ensure that the patient is doing well in terms of his health. The follow ups helps the health professional to assess whether the patient is adhering to the prescribed physical exercises. Through these referrals, the health professional manages to learn where they should intervene in terms of prescribing additional exercises or minimizing the level of exercises that the patient should undertake. In some situations, the health professionals decide whether or not to refer the patient to a more advanced health care facility.

References

Buck, C. J. (2018). Buck’s 2019 ICD-10-CM. Elserier

Chism, L. A. (2010). The doctor of nursing practice: A guidebook for role development and professional issues. Sudbury, Mass: Jones and Bartlett Publishers.

Dagenais, S., & Haldeman, S. (2012). Evidenced-based management of low back pain. St Louis, Mo: Mosby.

Hidalgo B, Detremblem C, Hall T, Mahaudens P, Nielens H., (2014). The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews. J Man Manip Ther, 22(2), 59-74.

Yoon JS, Lee JH, & Kim JS. (2013). The effect of Swiss ball stabilization exercise on pain and bone mineral density of patient with chronic low back pain. J Phys Ther Sci, 25(8), 953-956