Neuro Clinic

One afternoon a 67 year-old man presented to the emergency department of a small, rural hospital complaining of severe left leg and hip pain following a fall at home. The patient had no past history of falls. He had a history of impaired glucose intolerance, prostate cancer, hypercholesterolemia and hyperlipidemia. The patient’s current medications were atorvastatin and oxycodone for chronic back pain. The patient stated his pain was ten out of ten on a scale of one to ten with ten being the worst. The left leg appeared shorter than the right, edema was present in the calf, as was ecchymosis and he had limited range of motion. After an evaluation in triage by a registered nurse and a subsequent examination by the emergency department physician, a plan was established to sedate the patient using moderation sedation protocol and perform a manual reduction of the hip.

Turing and repositioning will avoid pressure from being exerted on one spot for too long (Miles, Nowicki, and Fulbrook, 2013). The nurse will also implement safety measures to prevent falling such as keeping the bed in the lowest position and hourly rounding (Crawford and Harris, 2016). The last priority nursing intervention for this patient is to get a set of vital signs before and after physical activity and prevent orthostatic hypotension. The patient can prevent orthostatic hypotension by adequate fluid intake, slow position changes and dangling the feet off the side of the bed before standing up (L. Schimke, J. Schimke,

Based on the progress report dated 08/23/16, the patient complains left knee pain upon walking. Discomfort was described as aching, tingling, intense, severe, continuous, pain, discomfort, increasing with movement and varying with activity. Pain is rated as 5/10 without medications and 4/10 with medications.

Possible symptoms of a herniated disc include pain that radiates through the back and possible down the arms or legs, depending on the location of the herniation. There can also be noted numbness and weakness of the arms and neck. Some people may not even know that they have a herniated disc because not all cases present with leg or back pain. Other signs and symptoms of a herniated disc may include muscle spasms or deep muscle pain. In extreme cases, a patient may present with weakness in both legs and/or the loss of bladder control and bowel control. This is a serious problem called cauda equine syndrome and requires immediate medical attention.

At today's visit he is accompanied by his wife. He is awake, alert and oriented. He reports that his back pain has improved with the pain regimen he was started on last Friday. He complains of lower back pain that he describes as achy and constant; he rates his pain as a 7/10 in severity. He states that his pain doe not radiate, but it affects his mobility and impedes his ability to get out of bed by himself. His pain regimen is Morphine ER 15 mg p.o every 12 hours and oxycodone/apap 10/325 mg p.o every 4 hours as needed for breakthrough pain. He has taken 6 as needed breakthrough doses daily since Friday. He states that his pain has improved but his goal is to have his pain a little better than 7/10, then he will be able to perform his ADLS

He was prescribed with the following: Neurontin 600mg 3 tablets daily #90 as it decreases numbness, improves walking and activity tolerance and has no side effects; Zanaflex 4mg, 1 tablet daily as needed #5; Zohydro 10mg, 1 tablet daily #30 with 1 refill as it decreases pain from 9/10 to 6/10, improves walking and activity tolerance, no side effects, no abuse or aberrant behavior, consistent urine drug screen, signed medication agreement and receives pain medication from a single provider; Norflex 100mg, 1 tablet daily as needed #25 with 1 refill as it relieves muscle spasm episodes which allows for increase in walking, exercise, and activities of daily living; Vistaril 25 mg decreased to 1 tablet at bedtime #25 as it improves sleep and increases daytime activity tolerance (2 months supply). Patient will follow-up in 2

The patient’s pain has clearly lasted beyond the anticipated time of healing. Previous methods of treating chronic pain have been unsuccessful and there is an absence of other significant options likely to result in significant clinical improvement. She has had conservative care including pain medication, braces/casts, physical therapy, transcutaneous electrical nerve stimulation unit (TENS), massage, exercise program, acupuncture, and chiropractic therapy. She is currently not a surgical

Review of diagnostic studies and medical-legal reports is included in the physician’s notes. Objective findings note that the patient is mildly obese and appears to be in moderate pain. He does not show signs of intoxication or withdrawal. His gait is antalgic gait and is assisted by cane. Lumbar range of motion is restricted with 50 degrees of flexion, 10 degrees of extension, 10 degrees of right lateral bending, and 10 degrees of left lateral bending. All range of motion is limited by pain. There is tenderness noted in the bilateral paravertebral muscles. Lumbar facet loading is positive on the left side. Ankle jerk is ¼ on the right and 2/4 on the left. Patellar jerk is ¼ on the right side and 2/4 on the left side. There is tenderness noted over the trochanter and pain to the lateral hip with range of motion. Right side motor strength of ankle dorsi flexor is 4/5 and ankle plantar flexor is 4/5. Hip flexor is 5-/5. Light touch sensation is decreased over the lateral calf on the left. Patient has resting tremor of the left lower extremity. His medications are Prilosec 20mg, Celebrex 200mg, Neurontin 800mg, Flexeril 10mg, Duragesic 75mcg/hour patch, Viagra 100mg, Nuvigil 150mg, and Silenor 6mg, Evzio 0.4 mg, and Norco

Based on the latest follow-up physiatric evaluation report dated 01/11/16, the patient complains of lower back pain which improves temporarily with PT but continues to radiate to his left leg with numbness, tingling and weakness. He attends PT three days per week and participates in a daily home exercise program.

The patient is a 70-year-old gentleman who presented with left hip pain of 3 weeks duration which has been worsening over the past 5 days 10/10 nonradiating pressure-like pain is worse on exertion and improved with rest is persistent. The patient's medical history is significant for gout, hypertension, diabetes, coronary disease, hypercholesterolemia, arthritis and nephrolithiasis. The patient had a right total knee replacement, 3 caths (the last one in 2003), a right rotator cuff repair, a right thumb injury and has had 6 previous hospital admissions for the right total knee replacement. Initial blood pressure is 169/70 with pulse 64 respirations of 20. The patient is afebrile and has a weight of 112 kg. The patient's physical exam is

Based on progress report dated 08/06/15, the patient complains of increasing low back and right lower extremity pain. Pain is rated as 6/10 with medications and 10/10 without medications.

Per the progress report dated 8/4/2016, patient returns with improving symptoms to her left knee and has been undergoing post-operative physical therapy times seven visits and has been utilizing Transcutaneous Electrical Nerve Stimulation (TENS) unit as well. She does still experience significant intermittent post-operative pain which she currently rates as 6/10 in intensity. Patient remains on her current oral analgesic mediations

12/18/15 Progress Report indicated that the patient presents with back pain radiating down his right leg; lower backache and right hip pain. The pain is 10/10-scale level without medications and 9/10-scale level with medications. His quality of sleep is poor. His activity level has remained the same. Current medications include Lidocaine 5 % patch, Cymbalta 30 mg and Vimovo Dr 500-20 mg.

Given the progression of symptoms, it will be necessary to intervene with therapies other than drugs. Patients will need help to walk and talk, and measures can be adopted for this purpose includes:

Introduce self to client, acknowledge visual impairment (reduces patient’s anxiety).Orient patient to environment. (Reduces fear related to unfamiliar environment). Do not make unnecessary changes in environment. Provide adequate lighting. Place meal tray, tissues, water, and call light within patient’s range of vision or reach. Communicate type and degree of impairment to all involved in patient’s care. Recommend use of visual aids when appropriate. Please food tray in the same place each meal and explain arrangement of food on tray and plate using clockwise sequence. Encourage sense of touch. Explain sounds or other unusual stimuli in environment. Encourage use of radios, tapes, and talking books. Remove environmental barriers to ensure safety. Discourage doors from being left partially open. Maintain bed in low position with side rails up, if appropriate. Keep bed in locked position to prevent falls. Guide patient when ambulating, if needed.