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NURS 624 Assignment 12.1 Musculoskeletal Case Scenario Michael 40- year- old Caucasian male
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NURS 624 Assignment 12.1 Musculoskeletal Case Scenario Michael 40- year- old Caucasian male
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• This is Michael, a 40-year-old Caucasian male.• Three months ago you saw him for sinus infection and
prescribed steroids and an antibiotic.
• CC: left sided low back pain (LBP)
• Initially, he rated his pain as a 10/10.
Allergies:
NKA
Family History
• Family History: Mother: 69, alive, recently diagnosed with lung
cancer, history of chronic back pain
• Father: 72, deceased, lung cancer
• Brother: 49, alive and well
Medications Currently Taking:
None (admits to taking several of his partner’s
hydrocodone/acetaminophen)
Personal History (PH)
• Long term monogamous relationship with male partner
• Smokes 1 pk/day cigarettes for 20 years
• Occupation: Employed. Construction work for 20+ years
Social History
• Employed. Works in construction.
• Smokes 1 pk/day for 20 years. Does not use illicit drugs.
• Alcohol: Drinks 2-4 drinks per week
Surgical History:
None
Here is a list of questions you should ask Michael:
, • Mode of onset: Did your pain come on suddenly or has it
progressively worsened?
• Characteristics: What provokes the pain, what relieves the
pain, what aggravates the pain?
• Effects of activities: Does the pain increase with coughing,
sneezing, or straining? Does the pain interfere with your ability
to sleep?
• History: Have you ever had pain like this before? If so, is the pain
similar or different?
• Course: Is it getting worse, staying the same, constant,
intermittent?
• Associated extremity symptoms? Numbness, paresthesia,
weakness,
atrophy, cramps.
• Associated symptoms: Urinary problems—frequency,
urgency, retention? Bowel problems—incontinence,
constipation?
• Previous back pain: What was the treatment—surgery? physical
therapy? medications? lifestyle/work modifications?
The pain began the day after I was working in the yard.
I had to move these garden stones and I guess I hurt it doing that. I would say the pain started off as a
10/10, but now it is more like an 8/10.
The pain gets worse if I try and do any type of activity. If I need to cough or sneeze, it just makes my
back hurt more.
It is really bad in the morning when I am trying to get out of bed.
I am having trouble sleeping because when I turn over in bed, it hurts so bad it wakes me up. Because I
am tossing and turning, my husband isn’t sleeping well either.
The pain is in my lower back on the left. It is constant and hasn’t stopped hurting since the yard. If I try to
twist to the left, that seems to really aggravate it.
I have used the heating pad, which helps a lot. But as soon as I take it off, the pain returns within a few
hours.
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