THIS IS DISCUSSION POST, 1 PAGE TO 1 PAGE 1/2 IS ENOUGH. APA FORMAT. MUST HAVE 3 REFERENCES.Topic: Neurological Case Study
A 49-year-old male with a history of hypertension presents to clinic with a 6-week history of back pain, along with right leg discomfort affecting his thigh and calf muscles. The pain has a burning and cramping quality and occasionally also affects the dorsum of his right foot. It is fairly constant but increases in intensity when he is walking or lying prone. The pain is improved when he is bending forward, such as when pushing a grocery cart or walking up stairs. It has significantly limited his walking distance and he now walks with a limp. He denies any urine or fecal incontinence. He denies a history of back trauma, rashes, weight loss, or night sweats. He does admit to lifting weights 3-4 days per week.
PE: T = 98.7, P = 86, BP = 162/87, R = 18, O2 sat = 96% on RA HEENT: No carotid bruits. Some slight painful limitation with forward flexion of the neck. Oropharynx is clear and neck is supple. Lungs: CTA, no respiratory distress with good air movement. CV: RRR without murmurs, rubs or gallop. No signs of CHF. Extremities are well perfused with 2+ distal pulses.
Abdomen: Soft, non-tender.
Musculoskeletal: No joint swelling or tenderness. Moderate percussion tenderness noted over lumbar-sacral spine. He is bent forward slightly at the waist and has discomfort with extension of his spine.
G/ U: Deferred.
MS: Patient is alert and fully oriented. Speech is fluent and articulate
CN: VA = 20/20 OU. PEERLA. EOMI. Face symmetric. SCM and trapezius strength full. Palate and tongue are midline.
Motor: UE’s have normal bulk, tone, and strength.
Case Questions:
- What are some appropriate questions to ask the patient?
- What is the diagnosis for the patient?
- What diagnostics would you include to diagnose the condition?
- Create an evidence-based plan of care. Include pharmacological and non-pharmacological treatments.
