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Sample Of Nursing Case Studies

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DOI: 10/3/1990. The patient is an 80-year-old male warehouseman who sustained cumulative trauma to his lumbar spine, left shoulder, neck and wrists.

As per medical report dated 09/26/16 by Dr. Cabayan, the patient presents using two canes and having issues with his balance with episode of almost complete fall. The patient has not worked for many years and have gained some weight. He is having left wrist pain. He has shooting pain from the back to the left lower extremity. He has quite a bit of problem with radicular component down the left lower extremity with pain radiating from the buttock down to the leg. The patient states that he can only walk for a few minutes and then his buttocks start hurting him and he has to stop, which suggests spinal stenosis per physician. He has numbness along the feet which could also be due to some neuropathy. The patient had MRI in 2014. The patient does have a hot and cold wrap and a two-lead transcutaneous electrical nerve stimulator unit. The patient does need a back brace. He does have a neck pillow, as well as neck traction kit. Chores are not being done. Lifting is curtailed to less than 25 pounds. The patient is sitting most of the time around the house. He is standing and walking no more than few minutes at a time.
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Review of systems is positive for issues with sleep, stress and depression. On examination, the patient has tenderness along the lumbosacral area. He has mild Tinel’s on the left wrist and tenderness along the shoulder with abduction of about 140 degrees and weakness to resisted function.
The patient is diagnosed with lumbar stenosis, discogenic cervical condition with headaches, impingement syndrome bilaterally, status post decompression on the right side, ankle sprain, depression, sleep and stress due to chronic pain, and carpal tunnel syndrome bilaterally, status post decompression on the
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