FIU Nursing The Treatment for Lumbar Disc Herniation Questions
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Case scenario 2: A 70-year-old male with PMH of CAD, DM, HTN, GERD, and Obesity who presents with low back pain onset 2 weeks ago. He described the pain as constant pressure to the lumbosacral region, radiating to bilateral legs, and worse when moving. He is concerned about low back pain because it limits his daily activity.
Write a brief SOAP note to answer the following questions:
- Subjective
- What pertinent information would you ask the patient?
- What are the risks factors of this patient?
- Objective:
- Complete the table below by filling out the possible disorders for a patient experiencing low back pain.FactorsPossible disordersAge >70 years oldIV drug useImmunosuppressionProgressive pain or weaknessWorse at restTearing or stabbingFeverWeight lossNight sweatsVascular symptomsBowel or bladder dysfunctionSaddle anesthesiaMedically inexplicable
- What objective findings require an emergent referral and why?
- What tests or procedures (Lab or Diagnostic) would you perform or order for this patient?
- Diagnosis:
- What are the top 3 differential diagnoses you would consider for this patient, and what is your rationale?
- What is the patient final diagnosis?
- Plan:
- What is the gold standard treatment for this patient?
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