Lumbar Radiculopathy - Essay Example

"Lumbar Radiculopathy" is an outstanding example of a paper on the musculoskeletal system.
After reviewing the case study, my top priorities for the patient in the assessment include; past medical history, current medical status, family history, physical symptoms, and BMI. In addition, it is critical to look at his lifestyle and diet, drug use, current medication, sleep pattern, allergies, and medical cover.

Current medical history

The patient is a 40-year-old Asian male who works as a roofer. He was involved in lifting heavy materials three days ago. The patient visits the clinic complaining of lower back pain that has persisted for a long and worsened in the last three days. He has taken over the counter drugs with no effect. The pain radiates from the mid lumbar zone to the right buttock. He also experiences tingling and numbness sensation from the back to the right thigh and proceeds to his toes. The pain increases when bending.

Vitals

• HR 92
• BP 120/78
• Ht 6ft
• Wt 220
• WC 40
• RR 18

Physical assessment

Examination of every system apart from the abdomen, pain in the posterior thigh, lower extremities, and android obesity, there is minimal strength on the right leg with opposed extension.

Lab tests

• Urinalysis to test for hematuria
• CBC
• H & P assessment
• Cholesterol tests

Radiology tests

A CT scan and X-rays are performed to assess sciatic nerve pain and bulging disc. The results indicated the degeneration of disc height and L5-S1. The MRI revealed a moderate disc bulge.

Substance misuse

• Marijuana
• Alcohol

Current medication

• OTC Sleeping pills
• Ibuprofen 800mg every four hours

Past medication

The patient received chiropractor services without any improvement.

Family history

His father and mother suffer from hypercholesterolemia and are under medication.

Psychosocial

The patient has suffered from depression for several years. He is on a temporary job where he is paid on basis of work done. He experiences disturbed sleep and is worried about his relationship with his ex-wife. He is not involved in any kind of physical activity and has gradual weight gain.

Medical cover

The patient does not have a health insurance cover.

Discussion of Diagnosis

According to the various test results, the patient is suffering from lumbar radiculopathy. Lumbar radiculopathy is the major cause of leg and back pain that can result in chronic and acute disability (DePalma, 2011). The common signs include sensory changes, for example, lower limb weakness, tingling or numbness, and low back pain that radiates to the lower limb. The disorder affects men from the age of 40 years and above (Wyss & Patel, 2013). The blood cholesterol test is crucial because familial hypercholesterolemia and hyperlipidemia can be inherited (Schwartz, 2012).

Plan

Since the patient does not have a health cover, it is advisable to refer him to a social worker. The social worker will help him with alcohol and marijuana rehabilitation. In addition, the social worker can assist the patient to procure cheap health care services through making referrals to federal and state agencies for medical and financial aid (Gehlert & Browne, 2013).  The social worker will carry out a thorough examination and care planning that will involve rehabilitation, therapy, recuperation, and re-incorporation with the community (Pierson & Thomas, 2010).

The patient is educated on appropriate diet and lifestyle changes to reduce the risk of diabetes type 2 and heart diseases (Bray & Bouchard, 2014). The change in diet includes fewer intakes of caffeine beverages and fast food. Instead, the patient is advised to consume a lot of fresh vegetables and fruits (Rippe, 2013).  In addition, the patient is advised to engage in physical exercises and will be informed about the most suitable one that will not interfere with the surgeon’s plan of care (Dannenberg & Berger, 2013). The patient will be given a prescription for sleeping drugs and pain relief. Tylenol OTC is given for pain and inflammation management (Medline Plus, 2015). The patient is given an outline of a future appointment that he should attend to monitor the effect of drugs on back pain and primary care (Buttaro, 2013).