23 hours ago Charlene Sanders Wk8Discussion Sciatica COLLAPSETop of Form Episodic/Focused SOAP Note Template Patient Information: DW 45 Caucasian Male S. CC:Back Pain HPI: David reports suffering from lower back pain. The painstarted approximately one month ago. It is a burning shooting pain thatradiates to his left leg. Sometime the pain is associated with numbnessin the left foot and tingling in the left leg. He mostly notices thepain when he’s been standing for an extended period of time. Standingmakes the pain worse but sitting seems to help. David has tried over thecounter medications including Tylenol, Motrin, and Aleve but none ofthose seem to make a difference. He’s also recently found somestretching videos online that seem to help reduce the number of what herefers to as ‘flare ups’ each day. He rates the pain as a 7/10 when heexperiences it but denies pain at this time. Current Medications: None Allergies: None PMHx: Childhood immunizations are up to date. Received the flu shot last week. Last Tetanus 2014.Soc Hx: David is a construction worker and cleans pools on theweekend. He is married with 2 adult children. David SCUBA dives and skydives recreationally but hasn’t recently. He denies any use of alcoholor recreational drugs. David was a pack/day smoker for 12 years but quit15 years ago. David never goes to the doctor but regularly monitors hisblood pressure at his local pharmacy. He does not have healthinsurance. Fam Hx: Father: deceased at 81- stroke. Mother: deceased at 83Alzheimer’s disease. Brother: deceased at 32- suicide. Sister: 41-Breast CA at 30. 3 other sisters and 2 brothers living. No otherpertinent family history. ROS: GENERAL: No weight loss, fever, chills, weakness or fatigue.HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.RESPIRATORY: No shortness of breath, cough or sputum.NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia. Nochange in bowel or bladder control. Numbness noted on occasion to leftlower leg and foot and tingling the radiates up and down his left leg.Weakness when standing for long periods.MUSCULOSKELETAL: Lower burning back pain that radiates to the left leg. O. Physical exam: From head-to-toe, include what you see, hear, andfeel when doing your physical exam. You only need to examine the systemsthat are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc. VS: BP 128/76; P 77; R 22; T 97.8; 02 98% Wt 220lbs; Ht 70” General–Pt appears in good health with a apple shaped abdomen. Appropriate. Alert, oriented. Cardiovascular–PMI is in the 5th inter-costal space at the midclavicular line. S1,S2. No murmur. No edema. Good radial and DP pulses.Cap refill <3secs. Pulmonary— Lungs are clear to auscultation and percussion bilaterally. Neurological— Good strength in all ext against resistance. Ableto lift legs bilaterally and hold. Pain in left buttock and lower backwhen lifting left leg off the bed. Differentiates between sharp and dullsensations throughout both lower extremities. No numbness or tinglingat this time. Musculoskeletal –Complains of pain in lower back and left buttockwhen lifting left leg off bed. Describes pain in lower back whenwalking on toes and heels. Complains of pain when asked to stand from asquatting position. Diagnostic results:Diagnostic results: MRI shows herniated disk at L1-L2. A.Differential Diagnosis:1) Herniated disk. This can cause nerve root irritation that may travel below the knee (Dains, 2019).2) Sciatica. The most common cause is a herniated vertebral disk orspinal stenosis (Mayo Clinic, 2019)Low levels of physical activity andobesity increase a patient’s risk of radiating low back pain (Shiri,2013). Occupations that require twisting and bending or carrying heavyloads can lead to sciatica pain(Mayo Clinic, 2019).3) Musculoskeletal strain. With this type of injury, patients oftenreport pain that is exacerbated by sitting or standing for long periodsof time (Dains, 2019). Patients often describe relief from pain withrest, as seen in this case (Dains, 2019).4) Spinal Stenosis. Spinal stenosis will result in pain whilewalking or standing for long periods of time that often gets better withrest or forward flexion of the spine (Dains, 2019). It is most oftenseen in patients over the age of 50 (Dains, 2019).5) Tumor. This is unlikely, but possible. Patients with tumorsusually present with weight loss, fatigue, weakness and anemia (Dains,2019). Primary Diagnosis/Presumptive Diagnosis: Herniated Disk and related sciatica pain. P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.ReferencesDains, J. E. (2019). Advanced health assessment and clinical diagnosis in primary care(Vol. 6). St.Louis, Missouri: Elsevier Mosby.Mayo Clinic. (2019, September 26). Sciatica. Retrieved from Mayoclinic.org: https://www.mayoclinic.org/diseases-conditions/sciatica/diagnosis-treatment/drc-20377441Shiri, R. S.-P.-J. (2013). The role of obesity and physical activityin non-specific and radiating low back pain: The Young Finns study. Seminars in Arthritis & Rheumatism, 42(6), 640-650.REPLY QUOTE EMAIL AUTHORBottom of Form Do you need a similar assignment done for you from scratch? We have qualified writers to help you. We assure you an A+ quality paper that is free from plagiarism. 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