Question

Joan Wright is an 84 year old female admitted to the medical surgical unit via the emergency department with complaints of persistent pain in lower back and hips after sitting down abruptly on the toilet. The client has a history of rheumatoid arthritis treated with steroids since 2001, diabetes mellitus type 2, hypertension, heart failure, COPD, peripheral artery disease, hypothyroidism, and depression since death of spouse 2011. The client’s daughter reports over the past year the client has been repeatedly hospitalized for both her heart failure and COPD but she has been doing well the last couple months. The daughter also states she has notified her mother is less able to do the things she normally does and is concerned her mother will have to be “put in a home.” The health care provider orders to continue home medications.

Home Medications
Metoprolol SR 25 mg once a day Furosemide 80 mg once a day KCl 80 mEq once a day Prednisone 10 mg once a day Calcium/vitamin D 500mg/200IU once a day Morphine SR 30 mg every 12 hours Morphine IR 5 mg every 4 hours as needed	NPH insulin 18units twice a day Mirtazapine 15 mg at bedtime Warfarin 2mg once a day Senna 2 tabs once a day Colace 100 mg twice a day Levothyroxine 50 mcg once a day Ranitidine 150 mg once a day Albuterol nebs every 3-4 hours as needed Ipratropium MDI every 6 hours

Based upon the client history, report from the daughter, and current medications where will you focus the assessment? Why?

What labs and diagnostic tests do you anticipate the health care provider will order? Why?

Answer 1

The patient was taking corticosteroids for rheumatoid arthritis since 2001 and which predisposes the vertebral compression fracture. Anticoagulant drugs also can increase the chance of low back pain related to the retroperitoneal hemorrhage.

Assessment:

To rule out the causes of pain, the healthcare personnel should do a thorough assessment of pain. Characteristics of pain such as location, associated symptoms, onset, duration - chronicity, severity, quality, mechanism of injury are assessed.

Location: localized or radiates

Which vertebra is affected?

In case of the intra-abdominal and retroperitoneal conditions causes or refer pain to the lumbar region

In the pelvic disorders, the pain refers to the sacral region.

Duration:

Acute or chronic onset

Psychosocial factors:

Orientation and mental status changes the explanation of pain

Joan Wright was suffering from depression since 2011, consider it while assessing pain

Relieving factors:

Like rest or sleep reduces pain

The onset of pain:

After which activity or when is it increased

Vertebral compression fracture

The most common reason for vertebral compression fracture is osteoporosis, trauma, and diseases affecting bone as in pathologic fracture. Osteoporosis will reduce the bone density and which will, in turn, increases the sustainability of vertebral compression fracture will little or no injury.

In case of Joan Wright, the predisposing factor is long-term corticosteroid therapy. Steroids decrease bone density in long course.

Laboratory tests:

Complete blood cell count:

Differential count, and ESR

Serum protein electrophoresis in suspected myeloma

Urine

Test for markers of increased bone turnover

Bence-Jones proteins in suspected multiple myeloma.

The diagnostic test which can be used:

• Radiography: Patients more than 65 years, suspected cancer, or significant trauma
• X-ray is the standard imaging study for spine fractures.
• Anteroposterior and lateral x rays are usually done to assess the extent of the fracture.
• CT scan of the spine: CT scan to perform to identify the extent of the fracture.
• MRI of the spine: To identify the extent of neurological
• Dual-energy radiographic absorptiometry (DRA) scanning is done to assess bone mineral density

·         Positron emission tomography (PET) scanning may be done to differentiate from malignancies and compression fractures