Complaining of upper back pain that radiates to right should

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Reference no: EM133923144

Case study: Patient is a 28 years old African American female who presents to the office complaining of upper back pain that radiates to the right shoulder that started 8 days ago while lifting a heavy bag of clothes. Per patient, she did Teledoc and was told to have an x-ray done which she went to the ER and had the x-ray done. Per the patient, the x-ray result was negative and was told it was just a soft tissue injury and was prescribed a muscle relaxant and told to rest for a couple of days. The patient complained of a pain level of 6/10 on the numerical scale in the office and described the pain as "tearing." Per the patient, the muscle relaxant was somewhat effective. On examination, upper extremity exam, R: (-)full range of motion, (+)pain with movement, Back exam, upper mid-back: (+)pain on palpation. PMH includes prediabetes, iron deficiency, dyslipidemia, vitamin D insufficiency. Differential diagnoses were 1. thoracic back pain, 2. intervertebral disc prolapse, and 3. spinal dysfunction. The patient doesn't smoke or drink.

Plan/Treatment:

The patient was instructed to continue taking the muscle relaxant prescribed when she went to the ER.

The patient was started on Prednisone 20 mg tablet 1 tab PO daily for 5 days for inflammation.

The patient was encouraged to exercise regularly at least 30 minutes three times a week to keep the back strong and flexible.

The patient was instructed to limit activities that cause pain.

The patient was advised to go for physical therapy to help with strength, flexibility, and range of motion.

Question

The student should reflect on this case and discuss whether or not they agree with their preceptor's treatment of the patient and why or why not. What did they learn from this case? What would they do differently?

Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).

Reference no: EM133923144

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