OBJECTIVE: Physical Exam: Vital signs: 128/70, right arm, sitting, regular cuff. Pulse:82 and regular. T: 98.7 orally. RR: 16, Unlabored. Oxygen saturation: 98% on room air. Ht: 6’0 Wt: 187 IBS. BMI: 25. General: Awake, alert, and oriented to person, place, time. No confusion or delirium noted. HEENT: Pupils 4mm: Bilaterally. Brisk. Pale, boggy nasal mucosa. Tonsils are not enlarged upon examination. No discharge noted from the nasal cavity. Neck: No lymph node enlargement noted. No JVD present. Chest/Lungs: Clear to Auscultate (CTA). No R/R/W (rhonchi, rales, or wheezes). Heart/Peripheral Vascular: RRR: Regular rate and rhythm. No murmurs, rubs, or gallops noted. No pedal edema. Pulses: 2+ strong and palpable dorsalis pedis pulses bilaterally. Abdomen: NABS: Normal Active Bowel Sounds auscultated in all four quadrants. No rebound tenderness noted. Musculoskeletal: Muscle strength 5/5 in all groups. Symmetrical muscle movement. Reports some discomfort but it wasn’t causing him significant pain upon examination. Skin/ Lymph nodes: Warm, moist. No cyanosis noted on exam. Diagnostic Results: Straight Leg Raising (SLR): Assessing for sciatic (L5 and S1) nerve root tension. A positive test, the patient will resist extension or will compensate with hyperextension of the spine. Range of Motion of the spine: Schober test: Assessing for lumbar mobility. Observe for limitation of motion on forward bending caused by hip flexion contracture. Magnetic resonance imaging (MRI): useful for evaluating soft tissue detail such as herniated disk. Electromyography: Assess the extent of nerve root compression. Used for chronic sciatica. ASSESSMENT: Differential Diagnosis: 1. Sciatica 2. Musculoskeletal strain
3. Herniated Disk 4. Spinal stenosis 5. Spinal fracture Sciatica: this condition is characterized by shooting pain that extends down the sciatic nerve into the hip, the thigh, and the back portion of the leg. Sciatica begins with a long period of intermittent low back pain. This is more than likely the cause of the patient’s pain. The two sciatic nerves are the largest nerves in the body. They run from the spine down either leg and connect the nervous system to the tissues of the thigh, lower leg, and foot (Slomski, 2017).
You've reached the end of your free preview.
Want to read all 5 pages?
- Summer '15
- Spinal disc herniation, Sciatica, Richard Hendrix