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Case File Nicole

The patient is a 67-year old retired male teacher presenting with back pain radiating to his legs for 1 week. He has a history of diabetes and hypertension. On examination, he has reduced range of motion and muscle strength in his lower limbs. The treatment plan includes pain management, exercises to improve range of motion and muscle strength, ambulation, patient education, and stretches with goals of improved mobility and self-care.

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juniourakello
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18 views

Case File Nicole

The patient is a 67-year old retired male teacher presenting with back pain radiating to his legs for 1 week. He has a history of diabetes and hypertension. On examination, he has reduced range of motion and muscle strength in his lower limbs. The treatment plan includes pain management, exercises to improve range of motion and muscle strength, ambulation, patient education, and stretches with goals of improved mobility and self-care.

Uploaded by

juniourakello
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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INSTITUTION: MASINDE MULIRO UNIVERSITY OF SCIENCE AND TECHNOLOGY

SCHOOL:PUBLIC HEALTH AND BIOMEDICAL SCIENCES

DEPARTMENT:HEALTH PROFFESION AND EDUCATION

NAME: NICOLE RONO

REGNO: SPR/B/01-03649/2022

YEAR TWO

CLINICAL PLACEMENT 1

CODE: BSP 228

SIGN

ROTATION: MALE MEDICAL WARD 1

CASE FILE

CLINICAL INSTRUCTOR:
NAME: PATRICK MUKOYA

AGE: 67

LOCATION: BULANDA, BUTERE

OCCUPATION: RETIRED TEACHER

RELIGION: CHRISTIAN

MARITAL STATUS: MARRIED

CHIEF COMPLAINT

The patient complains of back pain and pain on the legs that has disturbed him for 1/52.

PRESENT MEDICAL HISTORY

The patient states that he feels the pain in the lower back region and that it started a week 1/52 ago. It is
a dull pain that radiates from the back region towards the waist and to the legs. The patient feels the
pain more when he is engaging in activities such as walking and sitting for long periods of time and
relieves the pain by lying down. The pain is severe at random times of the day and on a scale of one to
ten he grades it a seven. He states that he was brought to the hospital after he fell unconscious after
experiencing headaches and weakness. He also complains of loss of appetite.

PAST MEDICAL HISTORY

The patient has no previous admissions.

The patient has a positive history of Diabetes and hypertension.

He is not allergic to any food or drugs.

The patient has no history of any previous surgeries done before.

He has never been involved in any accident before.

The patient has had a blood transfusion once on 22nd February 2024

The patient has never donated blood before

DRUG HISTORY

The patient does not take any alcohol or smoke.

The medications the patient has been taking is noglic and metformine to manage the diabetes condition.

The patient has not being taking any medications to manage the hypertension.

FAMILY HISTORY
The patient is married to one wife who is still alive. He has five children; two girls and three boys whon
are all alive.

He comes from a family of seven where he is the third born with one brother and five sisters.

Both his parents died of sickness.

There is no history of any chronic illness in the family except him who has diabetes and hypertension.

SOCIALHISTORY

He is a Christian and a retired teacher with no history of alcohol or cigarette use.

He lives in a permanent house in Butere

He has an NHIF cover that will cater for his treatment.

PERSONAL HISTORY

He loved his work as a teacher and his hobbies are spending time and playing with his children.

COGNITIVE HISTORY

The patient is alert, can communicate and of good cognitive history.

PSYCHOLOGICAL HISTORY

The patient is in a good emotional state.

OBJECTIVE ASSESMENT

VITALS

Blood pressure- 140/100

Temperature- 35.5

Pulse rate- 112

CARDIOVASCULAR SYSTEM

On inspection the patient looks healthy, no cyanosis observed, no finger clubbing observed, no edema,
no deep venous thrombosis.

On auscultation, the regular lub dub sounds are heard and absence of murmurs.

RESPIRATORY SYSTEM

There is equal chest wall expansion and no chest deformity observed on inspection.
No scars present also around the thoracic region.

The patient has a normal spine setting and no scoliosis.

The trachea is not shifted and is in the correct position and feels no pain on palpation.

No secretions present and resonant sounds heard.

Vesicular breath sounds bilaterally on auscultation.

ABDOMINAL EXAMINATION

There are no visible scars present

The bowel sounds are heard

MUSCULOSKELETAL SYSTEM

The patient experiences pain when trying to walk

Reduced range of motion on the lower limb.

Decreased muscle strength

PROBLEM LIST

Headache

Weakness

Back pain

Pain in the legs

Reduced muscle strength

Reduced ROM

TREATMENT PLAN

SHORT TERM GOALS

1.Pain management- by reducing the severity of pain from 7/10 to 2/10 during the first three sessions.

2.Increase ROM- by giving the patient passive and active assisted exercises

3.Improve muscle strength by giving the patient passive and stretching exercises
4.Enhance Mobility by ambulation getting up from a chair, and bending forward and bed sitting.

5.Strengthen Core Muscles: Strengthening core muscles (including abdominal and back muscles) to
provide stability and support for patients spine.

LONG TERM GOALS

1.patient to be able to attain full range of motion

2. the patients muscle strength to be increased and endurance also.

3. patient education on how to maintain good posture and self care techniques such as breathing
exercises to help alleviate and promote muscle relaxation

INTERVENTION

Breathing exercises to increase lung capacity such as deep diaphragmatic exercises.

Strengthening exercises to help increase muscle power

Active assisted exercise to help the patient

Patient education

Ambulation: ensure the patient tries to move about a number of times per day.

Passive stretches and self stretching exercises where the patient can do the stretches on their own to
help increase range of motion and strengthen the muscles.

EVALUATION

Analysis of the treatment the short term goals have been achieved

Patient condition has improved

REVIEW

The exercises should continue to be given.

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