DiagnosisThe review of systems of Mrs. Kingsley visiting the therapist with symptoms of back pain has revealed the only deviation from healthy norms: intense or very intense pain that tends to aggravate with physical activity. Mrs. Kingsley confided this back pain has been bothering her for almost three weeks. There was no apparent illness or injury that could have initiated the onset. The pain is across the entire low back and right buttock, going down into the back of the right thigh. Notably, there is no numbness or tingling. Mrs. Kingsley said the pain intensifies later in the day at work and becomes severe in the evenings. The only relief can be achieved with lying down and putting ice on the back. The patient has tried Motrin 800 mg every 6 hours, but it did not improve the condition. Mrs. Kingsley works as a toll taker on the turnpike, so she does not have enough physical activity through the day, as she has to either stand or sit without leaving her position. More importantly, Mrs. Kingsley confided she has a limited social life and spends much time indoors. The patient has been an active smoker for 19 years, and regularly consumes alcohol. She is 224 pounds, which is overweight for a 5’ 6” woman (Cadenhead Colgrove & Hargrove-Huttel, 2010).
Based on the lifestyle of the patient and enumerated symptoms, I suggested that Mrs. Kingsley’s diagnosis is chronic back pain due to the lack of physical activity and overweight (Nonas & Foster, 2009). Current research provides ample support for thus diagnosis. In particular, studies have found the connection between low back pain (LBP), obesity, and depression, which are highly prevalent health conditions among adults with a sedentary lifestyle (Häuser et al., 2014; Hershkovich et al., 2013). According to Balagué, et al. (2012), overweight adults have an increased risk of chronic low back pain, with smoking and genetic factors supposedly increasing this risk. Furthermore, Teichtahl et al. (2015) found that physical inactivity often leads to narrower intervertebral discs and high-intensity low back pain in adults. In line with these findings, Shiri et al. (2014) stated that overweight is a risk factor for lumbar radicular pain and sciatica in patients of both sexes. However, despite the available evidence, the accurate diagnosis should be supported by relevant examinations and tests (e.g. magnetic resonance imaging, X-rays, and computerized tomography) to exclude kidney problems, which the patient had two years ago, as well as other conditions that may cause back pain. Mrs. Kingsley has normal vital signs, no external lesions or masses, dysuria, hematuria, as well as a negative urine dip, so tumors and infections can be excluded from diagnosis (Goroll & Mulley, 2011).
When the diagnosis was supported by relevant tests, I used this data to develop a treatment plan for the patient. First of all, we had a thorough discussion of Mrs. Kingsley’s need to take a sick leave for at least one week to conduct proper treatment. Second, I suggest standard treatment options for overweight patients with severe back pain, including medications and non-pharmacologic modalities. For most overweight patients in pain, opioids such as Vicodin, for example, are considered for pain management, but these medications will be prescribed to Mrs. Kingsley only when renal dysfunction, diabetes, and the potential for gastric bleeding are excluded (D’Arcy, 2011). Furthermore, given the fact that exercise and diet interventions seem to be the most effective in overweight patients with low back pain, these interventions will be the primary steps recommended to the patient (Balagué, et al., 2012).
Other interventions including stress management, back supports, health-promoting activities, and training may also be useful, but the outcome depends much on Mrs. Kingsley’s determination and desire to change her lifestyle. In general, self-management, with appropriate nursing support, is recommended to the patient, while surgery and overtreatment will be avoided. Outcomes expected as a result of this treatment include pain reduction, weight loss, and increased wellbeing, but the general improvement may be observed only in several weeks after initiation of treatment. In case no betterment is observed, treatment plan adjustments may be considered. A follow-up visit was scheduled with Mrs. Kingsley in 7 days for examination to identify the effectiveness of prescribed medication.
Patient Involvement and Socio-cultural Background
Before designing a treatment plan, I discussed the diagnosis with Mrs. Kingsley to check her overall understanding of the disease and level of diagnosis acceptance. The patient agreed with the diagnosis and suggested interventions, stating that she has already considered changing her lifestyle and diet. I informed Mrs. Kingsley about the seriousness of her condition and potential complications that non-adherence with treatment may bring. I also informed her about the danger of continuing smoking and consuming alcohol. I ensured that Mrs. Kingsley is determined to change her lifestyle in terms of diet and physical activity, and discussed the issues of insurance to make sure that the patient can afford drugs I prescribe to her. Mrs. Kingsle explained that she has little emotional and social support, which often induces her to eat and drink more. Therefore, I determined that besides standard treatment interventions, the patient has to improve her emotional and mental condition. To obtain professional help in this relation, I suggested Mrs. Kingsle to visit psychotherapist and socialize more with her friends and boyfriend.
Education and Prioritization
In terms of patient’s minor issues, I would consider the history of kidney stone in the past. This condition means that Mrs. Kingsle still needs a particular diet, and she should care more about her lifestyle. The fact that Percocet causes nausea and vomiting is a minor issue that I would not prioritize, taking into account that there are many other drugs used to eliminate pain. Issues of major concern about which I would educate Mrs. Kingsle include paying more attention to physical exercises and diet, since her weight and a lack of activity are the main causes of her condition. I would strongly recommend smoking cessation and reduced alcohol consumption because of the overall negative impact they have on the patient’s health.
- Balagué, F., Mannion, A. F., Pellisé, F., Cedraschi, C. (2012). Non-specific low back pain. Lancet, 379, 482-91.
- Cadenhead Colgrove, K., & Hargrove-Huttel, R. A. (2010). Med-surg success: A Q&A review applying critical thinking to test taking. Philadelphia, PA: F.A. Davis.
- D’Arcy, Y. (2011). Managing pain in obese patients. The Nurse Practitioner, 36(12), 28-32. Retrieved from http://www.nursingcenter.com/cearticle?tid=1263909.
- Goroll, A. H., & Mulley, A. J. (2011). Primary care medicine: Office evaluation and management of the adult patient. Philadelphia, PA: Lippincott Williams & Wilkins.
- Häuser, W., Schmutzer, G., Brähler, E., Schiltenwol, M., & Hilbert, A. (2014). The impact of body weight and depression on low back pain in a representative population sample. Pain Medicine, 15(8), 1316-1327.
- Hershkovich, O., Friedlander, A., Gordon, B., Arzi, H., Derazne, E., Tzur, D… Afek, A. (2013). Associations of body mass index and body height with low back pain in 829,791 adolescents. American Journal of Epidemiology. Retrieved from http://aje.oxfordjournals.org/content/early/2013/05/17/aje.kwt019.full.
- Nonas, C., & Foster, G. D. (2009). Managing obesity: A clinical guide. American Dietetic Association.
- Shiri, R., Lallukka, T., Karppinen, J., & Viikari-Juntura, E. (2014). Obesity as a risk factor for sciatica: A meta-analysis. American Journal of Epidemiology. Retrieved from: http://aje.oxfordjournals.org/content/early/2014/02/23/aje.kwu007.full.
- Teichtahl, A. J., Urquhart, D. M., Wang, Y., Wluka, A. E., O’Sullivan, R., Jones, G., & Cicuttini, F. M. (2015). Physical inactivity is associated with narrower lumbar intervertebral discs, high fat content of paraspinal muscles and low back pain and disability. Arthritis Research & Therapy, 17(114). doi:10.1186/s13075-015-0629-y