genital urinary and musculoskeletal assessment paper

genital urinary and musculoskeletal assessment paper

Genital urinary and musculoskeletal assessment

Lower back pain for two days

History of the presenting complaint

B.W is a 35 years old male who presents with Lower back pain for two days. The pain was of acute onset, sharp and stabbing in nature, and was not radiating. The pain was so severe on the right lower back at a scale of 9 out of 10. The pain was aggravated by lifting a 5-gallon paint can and it could not reduce after taking Motrin. He denies a history of generalized body weakness, fatigue, and numbness. genital urinary and musculoskeletal assessment paper

PMH The patient is known to have right leg pain with no bowel or bladder changes. No history of previous admission, blood transfusion, and chronic illness.

Current medication: Motrin for pain

Allergies: none

Personal social-economic history: The patient is a professional painter. He is married and lives with his wife and two children. He denies smoking and drinking alcohol.

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Family history: He is the firstborn in a family of seven. His siblings are alive and healthy. His father is hypertensive and is on follow-up. His mother has osteoarthritis of the pelvic bone and she is on treatment.

Surgical history: he denies a history of minor or major surgical procedures.

Review Of Systems

General: He denies a history of fever, weight loss, and persistent fatigue.

HEENT:

Eyes: no visual loss, blurred vision, double vision, or yellow sclera.

Ears, Nose, Throat: no hearing loss, sneezing, congestion, runny nose, or sore throat. genital urinary and musculoskeletal assessment paper

Skin: no rash or itching.

Cardiovascular denies chest pain, chest pressure or chest discomfort, or edema.

Respiratory: he denies cough or sputum, chest pain.

Gastrointestinal: Denies having diarrhea and constipation, abdominal discomfort and cramping, incomplete emptying of the bowel, and unexplained weight loss.

Genitourinary: Denies burning sensation on urination,

Neurological: no headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities, no change in bowel or bladder control.

Musculoskeletal: Lower back pain, and right hip joint pain, no tingling or burning sensation of the extremities.

Hematologic: No anemia, bleeding, or bruising.

Lymphatics: Has enlarged nodes, no history of splenectomy.

Endocrinology: no reports of sweating, cold, or heat intolerance. No Polyuria or Polydipsia. genital urinary and musculoskeletal assessment paper

Allergies: none

Objective Data

Physical examination

General: The patient is a well-developed healthy 35 years old male with no gross deformities. He is clinically afebrile, with no pallor, jaundice, edema, dehydration, lymphadenopathy, and cyanosis. genital urinary and musculoskeletal assessment paper

Local examination:

Vitals: Temperature 98.2 F, respiratory rate 16, heart rate 90, blood pressure at 120/60, and oxygen saturation at 98%.

HEENT: Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, poor dentition, and multiple carries.

Lungs: CTA/AP/l. Lung fields have symmetrical chest expansion, no scars and mass. There are normal vesicular breath sounds. No crackles and transmitted sounds.

Cardio: S1 S2 heard without gallop, normal-active precordium, pulse is present at a normal rate and volume with a regular rhythm. Parasternal heaves are not palpable. No murmurs.

Breast: both breasts have a normal skin color, no obvious mass or scar, no dimpling or abnormalities noted upon inspection. The nipples are everted with a dark areola and no nipple discharge. No tenderness or pain and abnormalities detected on palpation. No axillary lymphadenopathy. genital urinary and musculoskeletal assessment paper

Lymph: no bruising, fever, swelling, acute bleeding, or trauma to the skin.

Abdominal: Benign normal active bowel sounds, hepatomegaly 2cm below the coastal margin, mild abdominal distention, tympanic percussion note, no tenderness, and no shifting dullness. No palpable mass.

Genital urinary: bladder is non-distended and no supra-pubic tenderness. genital urinary and musculoskeletal assessment paper

Integument: The skin is intact without lesion or rashes

Musculoskeletal: No obvious deformities, masses, discoloration, palpable pain at noted at the right lower lumbar region, no palpable spasms, there is limited forward bending 10 inches from the floor, able to bend side by side, and difficulty in twisting and going to extension.

Neurological examination: Lower sensory neurology intact to light touch. The patient can heel walk, the gait is stable and no limping noted. Sensation and reflexes are intact

Diagnostic investigations

Plain lumbar-sacral x-ray is necessary for this patient to identify sine instabilities of preexisting tumors. Computed tomography is important in evaluating spondylotic changes. MRI is accurate in identifying disc abnormalities.

Assessment

Differential diagnoses for this patient are lumbar compression fracture, lumbar disc disease, and lumbar spondylosis.

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The Rationale For The Differential Diagnosis

A lumbar compression fracture is lower back pain that is severe, sharp and stabbing in nature. The pain does not radiate, very severe, and disabling. The common cause of lumbar-sacral compression is trauma (Takahashi, et al, 2020). Lumbar disc disease presents with lower back pain associated with trauma or work-related injuries (Lee, et al, 2018). Other factors determining lumbar disc disease are obesity and smoking which causes degeneration of the disc. Lumbar spondylosis is the formation of a new bone at the margins of the disc (Park, et al, 2019). It presents with lower back pain, numbness of extremities, and stiffness. genital urinary and musculoskeletal assessment paper

Teachings I would provide

The definitive diagnosis for this patient is a lumbar compression fracture caused by trauma. I would advise the patient to ensure complete bed rest to reduce the pain and allow the union of the fracture. In the future, the patient should avoid lifting to prevent recurring. The panting companies should invest in having raised and wheeled trolling for paint carrying to avoid trauma to the back. genital urinary and musculoskeletal assessment paper

Case Study 3 Chief Complaint- “My back hurts so bad I can barely walk” History of Present- A 35-year-old male painter presents to your clinic with the complaint of low back pain. He recalls lifting a 5-gallon paint can and felt an immediate pull in the lower right side of his back. This happened 2 days ago and he had the weekend to rest, but after taking Motrin and using heat, he has not seen any improvement. His pain is sharp, stabbing, and he scored it as a 9 on a scale of 0 to 10. Drug HX Motrin for pain. Family Hx-> Father hypertension Subjective- He is having some right leg pain but no bowel or bladder changes. No numbness or tingling VS-> temperature: 98.2°F, respiratory rate 16, heart rate 90, blood pressure 120/60 O2 saturation 98% General-> well-developed healthy 35-year-old male; no gross deformities HEENT-> Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries. Lungs CTA AP&L Cardio S1S2 without rub or gallop Breast-> INSPECTION: no dimpling or abnormalities noted upon inspection • PALPATION: Left breast – no abnormalities noted. Right breast – denies tenderness, pain, no abnormalities noted. Lymph-> no bruising, fever, or swelling noted, no acute bleeding or trauma to skin. Abd benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin. GU-> Bladder is non-distended. Integument-> intact without lesions masses or rashes. MS-> No obvious deformities, masses, or discoloration. Palpable pain noted at the right lower lumbar region. No palpable spasms. ROM limited to forward bending 10 inches from floor; able to bend side to side but had difficulty twisting and going into extension. Neuro DTRs 2+ lower sensory neurology intact to light touch and patient able to toe and heel walk. Gait was stable and no limping noted. Answer the following questions: 1. What other subjective data would you obtain? 2. What other objective findings would you look for? 3. What diagnostic exams do you want to order? 4. Name 3 differential diagnoses based on this patient presenting symptoms? 5. Give rationales for your each differential diagnosis. 6. What teachings will you provide? Submission Instructions: Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources current (published within the last five years-2016-2021) scholarly journal articles). genital urinary and musculoskeletal assessment paper

References

Lee, S. H., Yun, S. J., Jo, H. H., Kim, D. H., Song, J. G., & Park, Y. S. (2018). Diagnostic accuracy of low-dose versus ultra-low-dose CT for lumbar disc disease and facet joint osteoarthritis in patients with low back pain with MRI correlation. Skeletal radiology, 47(4), 491-504.

Park, M. S., Ju, Y. S., Moon, S. H., Kim, T. H., Oh, J. K., Lim, J. K., … & Chang, H. G. (2019). Repeat decompression and fusions following posterolateral fusion versus posterior/transforaminal lumbar interbody fusion for lumbar spondylosis: a national database study. Scientific reports, 9(1), 1-9.

Takahashi, T., Takada, T., Narushima, T., Tsukada, A., Ishikawa, E., & Matsumura, A. (2020). Correlation between bone density and lumbar compression fractures. Gerontology and Geriatric Medicine, 6, 2333721420914771. genital urinary and musculoskeletal assessment paper