Carlotta Russe 020121 case study 2021/22 latest 100% graded A

HPI: Carlotta Russe is a 65 yo Caucasian female presenting to the clinic with complaints of moderate low back pain that began 2 days ago after moving heavy tables at work. She reports that the pain radiates into her R buttocks and down her R leg. She reports sharp, constant pain at 7/10. She reports that the pain is made worse with activity, not relieved by anything and awakens her from her sleep. She denies taking medications to treat the pain. She denies bowel or bladder dysfunction or numbness/tingling. Physical exam reveals inability to bend at the waist as well as limited ROM in RLE with slightly diminished sensation and hypo reflexive patellar DTR. PMH significant for osteoporosis with last bone density test over 1 year ago, score -2.5; chronic asthma with recent attack, currently being managed with prednisone taper; hx of surgical menopause at age 42and HTN. Lumbar Disc Displacement (Disc Herniation) M51.27 – Based on patient’s complaint of acute low back pain after moving heavy tables at work and her physical exam findings of limited range of motion, unrelieved pain at rest or with movement and diagnostic imaging, it can be concluded that Carlotta has L4/L5 herniated nucleus pulposus with associated right sided L4 radiculopathy. Lumbago with Sciatica R M54.41 – Based on patient’s complaint of acute low back pain after acute injury at work and physical exam findings of LROM, worsening pain with movement, hypo reflexive patellar DTR and diminished sensation and positive leg raise exam, it is suspected that she has sciatic involvement. Further confirmation of sciatic involvement can be seen on diagnostic imaging. Compression Fx S32.0 – Based on patient’s complaint of back pain after moving heavy tables at work, age of 65 years and history of osteoporosis, it is possible that the patient could have sustained a stress/compression fracture. She also has a long history of steroid use that contributes to her diagnosis of osteoporosis. In the United States, a woman older than 50 has a 40% chance of developing an osteoporotic compression in her lifetime. Radiographic studies show that 8-13% of women in their 60s and 30-40% of women in their 70s are found to have evidence of vertebral compression fractures on plain radiographs in epidemiological studies (Tsuda, 2017, p. 584). I was able to rule out this diagnosis based on diagnostic imaging and confirmation of disc herniation, however, based on T score of 2.5, the patient is due for a repeat bone density scan and should be scanned yearly. Additional labs and diagnostic test: Diagnostic imaging includes spine xray and lumbar spine MRI. For additional confirmation of compression fracture, a lumbar spine CT would be necessary. Carlotta is also due for a BMD test as her most recent exam was over 2 years ago. Based on her age of 65 and T score of -2.5, continued smoking and prednisone use, she should be tested yearly. Consults: I would refer this patient for physical therapy and chiropractic services for evaluation and treatment. I would also f/u with pulmonology regarding Carlotta’s continued use of prednisone 30mg and findings during assessment. Therapeutic Modalities: Physical therapy is an important treatment modality and it is important to initiate it as soon as possible. Understanding that the patient is in pain with movement, it is important to advise the patient to avoid bedrest. When a referral for physical therapy is warranted for patients with This study source was downloaded by from CourseH on 07-11-2022 06:56:23 GMT -05:00 acute LBP, immediate referral and initiation (within 3 days) may lead to lower health care utilization and LBP-related costs (Liu et al., 2018, p. 339).