Case Study: 

Mrs. Russe is a 65-year-old female who presents with back pain. Two days ago, the patient had acute, sharp, lower back pain, 7/10 in severity, radiating down her right leg following rearranging heavy tables at work. The pain is continuous impacting her sleep. Moving worsen the pain, even rolling over in bed or walking. Physical examination demonstrates RLE sensory deficit, RLE Motor deficit, and hyporeflexia as well as testing positive for contralateral SLR. The patient also self-reported numerous possible medical problems, such as asthma, hypertension, and osteoporosis.

 

Instructions: Answer the following questions. As you can see, I already have the primary, differential diagnosis, and diagnostic test.

 

Management Plan Template: 

(Every section of your management plan must have intext citations to support your plan).

 

Primary Diagnosis and ICD-10 code: Also include any procedural codes.

3-5 Differential Diagnoses- Why? What made you select each one as a DDX? How did you rule out? This would be a good area to include references.

 

Primary Diagnosis:

     Disk Herniation M51.06

 

Differential Diagnosis:

    1. Compression Fracture S22.000A

    2. Spinal Neoplasm C72.0

    

Additional laboratory and diagnostic tests: May be necessary to establish or evaluate a condition. Some tests, such as MRI, may require prior authorization from the patient’s insurance carrier.

 

 Diagnostic tests:       

         – Spine x-ray

         – Lumbar spine MRI

 

Consults: referrals to specialists, therapists (physical, occupational), counselors, or other professionals. If you are sending to hospital, what orders would you write for a direct admit?

 

Therapeutic modalities: pharmacological and nonpharmacological management.

 

Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening.

 

Patient education: Explanations and advice given to patient and family members.

 

Disposition/follow-up instructions: when the patient is to return sooner, and when to go to another facility such as the emergency department, urgent care center, specialist, or therapist.

 

 Scholarly references (minimum of 3, timely, that prove this plan follows current standard of care).\\\\\\\”

 

 

 

 

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