Download Betty Burns Ihuman case chief complaint Severe Atraumatic Lower back pain and more Exams Nursing in PDF only on Docsity!
Iām having terrible back pain. I must have thrown my back out. Do you have night sweats? Actually, yes. Itās like stating menopause all over again. What does that have to do with anything though? Have you gained of lost weight unintentionally,despite normal appetite and exercise? Yes, actually. Iāve lost about 20 pounds in the last 6 months without really trying. Do you have any pain in your abdomen? No, itās more of a matter of fullness of heaviness on the upper right side of my abdomen. I wouldnāt call it pain. Have you been having fevers? No fevers of chills. Do you have any numbness and/or tingling anywhere? My right leg feels a little numb and tingling on the outside of my thigh. Do you have any other symptoms of concerns we should discuss? Right now, you mean? All I can think about is my back.
Betty Burns Ihuman case chief complaint Severe Atraumatic Lower back pain
iHuman Week 9 Case Study - Betty Burns ā 53yĆs old Female CC: Severe Atraumatic Lower BackPain How can I help you today?
Does the pain in your back radiate someplace else? Where? Yeah, I can feel it in my right leg and sometimes all the way to my foot. Itās not in my footoĆ anything, but mostly in my thigh. Where more precisely is the pain in your back? It seems to be my lower back. Does the pain awaken you from sleep? Yeah, I wake up every time I move even a tiny bit in bed.the pain wakes me up. Do you have pain/discomfort when you are at best? Yes, itās pretty constant. Does the pain in your back keep you from sleeping? It doesn't keep me from falling asleep. What does the pain in your back feel like? It is really sharp, stabbing, gnawingā¦ What were the events surrounding the start of your back pain? It hit me as I was lifting a heavy laundry basket full of wet clothes. Wham! Out of nowhere. When did the pain in your back start? Does anything make the pain in your back better or worse?
Do you have pĆoblems with dizziness, fainting, spinning Ćoom, seizuĆes, weakness, numbness,tingling, oĆtĆemoĆ? No spinning oĆ passing out oĆ anything like that.SeizuĆes?! LoĆd no! Do you have any pĆoblems with an itchy scalp, skin changes, moles, thinning haiĆ, oĆ bĆittle nails? Nope. Do you have any pĆoblems with fatigue, difficulty sleeping, unintentional weight loss oĆ gain, feveĆs,oĆ nightsweats? Yes, a bunch of that. What do you want to know about? When you uĆinate, have you noticed any pain, buĆning, blood, difficulty staĆting oĆ stopping, dĆibbling,incontinence, uĆgency duĆing day oĆ night, oĆ any changes in fĆequency? Uhā¦no. Do you have any pĆoblems with headaches that don't go away with aspiĆin oĆ Ä¾ylenol (acetaminophen), double oĆ bluĆĆed vision, difficulty with night vision, pĆoblems heaĆing, eaĆ pain,sinus pĆoblems, chĆonic soĆe thĆoats, oĆdifficulty swallowing? No. Have you noticed any bĆeast dischaĆge, lumps, scaly nipples, pain, swelling oĆ Ćedness? EveĆything is totally fine heĆe. ľhank the LoĆd. Do you expeĆience chest pain discomfoĆt oĆ pĆessuĆe; pain/pĆessuĆe/dizziness with exeĆtion oĆ getting angĆy;palpitations; decĆeased exeĆcise toleĆance; oĆ blue/cold fingeĆs and toes?
Do you have pĆoblems with nausea, vomiting, constipation, diaĆĆhea, coffee gĆounds in youĆ vomit,daĆk taĆĆystool, bĆight Ćed blood in youĆ bowel movements, eaĆly satiety, oĆ bloating? o No. Physical Exams Blood PĆessuĆe Do actually peĆfoĆm, open the electĆonic health ĆecoĆd to view. o 142/80 left o 144/82 Ćight Elevated NoĆmal pulse pĆessuĆe Pulse Do NOľ actually peĆfoĆm, open the electĆonic health ĆecoĆd to view. o 88bpm o RegulaĆ Ćhythm o NoĆmal stĆength Examine Pupils I need help with Betty Burns ihuman questions to ask the patient. She is a 53 y.o female who presents with back pain. Uhā¦no. Do you expeĆience shoĆtness of bĆeath, wheezing, difficulty catching youĆ bĆeath, chĆonic cough, oĆ sputumpĆoduction? Not now.
- Betty's back pain is helped by lying down and gets worse when she stands or sits for
extended periods of time. For her back problems, Betty is now taking ibuprofen without
a prescription. Although it is reducing the pain, it does not entirely take away the
discomfort. In the past, Betty attempted massage therapy and physical therapy, both of
which relieved her back pain. But the discomfort always came back eventually.
- In general, Betty's health is excellent. We are not aware of any more medical issues with
her. Betty works as a receptionist at the moment. She worries about going backto work
because she must sit for extended periods of time. Betty wants her back pain fully gone
as a result of her treatment. At this point, Betty has no queries or worries concerning the
causes of her back discomfort or the available treatments.
What are the 27 required history questions you ask I human Betty Burns?
1. When and where were you born?
2. Who are your parents?
3. Do you have any siblings?
4. Where did you grow up?
5. What is your educational background?
6. What is your occupation?
7. What are your hobbies and interests?
8. What is your marital status?
9. Do you have any children?
10. What is your religious affiliation?
11. What is your political affiliation?
12. Are you a member of any clubs or organizations?
13. What is your favorite food?
14. What is your favorite color?
15. What is your favorite music?
16. What is your favorite movie?
17. What is your favorite book?
18. What is your favorite sport?
19. What is your favorite vacation destination?
20. What is your favorite thing to do on a weekend?
21. What is your favorite thing to do for fun?
22. What is your favorite way to relax?
23. What is your favorite thing to do when you have free time?
24. What is your favorite thing to do on a rainy day?
25. What is your favorite thing to do on a sunny day?
26. What is your favorite season?
27. What is your favorite holiday?
Step-by-step explanation
History questions are questions that ask about the past. They are important because theyhelp
us understand the present and make decisions about the future.
- The first step in the diagnostic process should be to evaluate her symptoms and make
sure they are not due to another underlying cause. For example, she reports having focal
neurologic deficits in her lower extremities and numbness on one side of her body. The
differential diagnosis for Betty Burns' case study is fairly straightforward, but it is
important to note that the patient's previous history of breast cancer could have been a
contributing factor to her low-back pain. As such, itwould be prudent to rule out any
could be indicative of a spinal lesion or spinal cord compression caused by cancer
metastasis or other types of tumors. In order torule out this possibility, an MRI or CT
scan should be ordered immediately and reviewed by a radiologist with experience in
reading these types of scans.
- If no spinal lesions are found on the scan, then a thorough physical exam should be done
to assess for any abnormalities in sensation or motor function that may be present
throughout her body. A complete blood count (CBC) and comprehensive metabolic
panel (CMP) may also be ordered if there are any abnormal findings during this
evaluation period that require further investigation into potential infectious causes such
as viral infections like herpes z In this case, the differential diagnosis includes several
possible causes of low-back pain, including disc herniation, spinal stenosis, or sacroiliac
joint dysfunction. In addition to low-back pain, Betty Burns could have developed focal
neurologic deficits as a result of one ofthese conditions.
Low-back pain is a common problem that can be caused by many things. Disc
herniation and spinal stenosis are two common causes of low-back pain. Disc
can cause numbness or weakness in the part of the body innervated by
the nerve root being pinched (1). Spinal stenosis is caused by
compression on one side of the spinal cord due to narrowing of the
bony canal through which it passes (2). Numbness or weakness may
also be present with this condition (3).Sacroiliac joint dysfunction is
another possible cause for Betty's back pain and neurologic symptoms.
The sacroiliac jointsare located on either side of your spine where each
half joins your pelvis to form your buttocks (4). They play an important
role in supporting your
herniation occurs when the soft center of an intervertebral disc pushes
against an adjacent nerve root and pinches it in the spinal canal. This
