1 Spinal fracture Patient could have more seriously injured her back that we

1 spinal fracture patient could have more seriously

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1. Spinal fracture: Patient could have more seriouslyinjured her back that we originally thought. We wouldneed to perform an x-ray or a CT to have a look atthe spine.2. Spinal Stenosis: Spinal stenosis is generally abilateral pain that can radiate to the buttocks and theupper legs. A lumbar MRI or CT could help us withthis diagnosis.Low back muscle strain related to liftingPlanI would like to prescribe the Ms. Jones ibuprofen800mg every six to eight hours for consistent pain forthe next two weeks. I will also prescribe 800mg ofacetaminophen to be taken every 8 hours asneeded. I will also educate the patient on proprerlifting techniques so that this can be avoided in thefuture. I would also educate Ms. Jones on the use oftopical heat and ice methods to help with pain.I would educate the patient on when she should seekemergent care. This would be if she starts exhibitingsymptoms like radiating pain into her limbs, loss ofsensation in the limbs, or changes in bowel orbladder function.If the symptoms do not resolve, I would like to seethe patient back in the clinic in two weeks.Diagnostics• None at this timeMedication• Initiate treatment with ibuprofen 600 mg by mouthevery six to eight hours with food as needed for painfor the next two weeks• She may use acetaminophen 500-1000 mg bymouth every 8 hours for breakthrough painEducation• Provide Ms. Jones with materials detailingstretching techniques for the lower back• Encourage Tina to be active and avoid prolongedperiods of lying down• Ms. Jones can also use adjunct therapy of topicalheat or ice per comfort TID-QID• Educate on proper body mechanics and liftingtechniques• 10-pound lifting restriction for 10 daysReferral/Consultation• Referral to physical therapy if symptoms persist intwo weeksFollow-up Planning• Instruct Tina to seek emergent care including lossof bowel or bladder function, acute changes insensation of lower extremities, or limitations inmovement of lower extremities• Return to clinic in 2 weeks for follow up andevaluation of symptomsMusculoskeletal Physical Assessment Assignment | Completed | Shado...3 of 411/20/2018, 5:57 PMThis study resource wasshared via CourseHero.com
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CommentsIf your instructor provides individual feedback on this assignment, it will appear here.Musculoskeletal Physical Assessment Assignment | Completed | Shado...4 of 411/20/2018, 5:57 PMThis study resource wasshared via CourseHero.comPowered by TCPDF ()
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