Case Study On Back Pain

Running head: CASE ANALYSIS 1

Case Analysis

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CASE ANALYSIS 2

Case study on Back pain

Introduction

The human back is made of a complex network of muscle structure, bones, tendons and

ligaments which coordinate together for perfect functioning of the back to enable individuals to

move around. Back pain is a common reason that could lead people to be absent from work to

create time to seek medical attention and treatment. The pain can be severe and chronic to the

point of causing discomfort and disconnect with normal body operations. Back pain may result

from injury, old age, and certain medical conditions.

Here is a case of a 45-year-old woman with a Past medication history of Type II diabetes

since age 27, High blood pressure, Recurrent DVT’s complains of back pain and fatigue. The

back pain, she states has been there for the last ten years. However, she denies any back injuries,

weakness of the lower extremities, bowel or bladder changes, radiation of pain to the lower

extremities and dysfunctional issues. Also, she has never experienced numbness or tingling in

the lower extremities. Her recent medications include creatin, Coenzyme Q10, Kava Kava,

garlic, Glyburide 3 mg daily with breakfast, Lisinopril 20 mg daily and Coumadin 6 mg daily

From the medical conditions described including the workout program, Coumadin 6

occurs naturally in the body, and it is a nutrient found in many foods that people eat. It is also an

antioxidant hence protects the cells from damage (Searle, Spink, Ho & Chuter, 2015). However,

the Q10 is mostly associated with blood pressure where it lowers the blood pressure and also

could treat heart failure and other heart conditions. Its use by the patient was somehow not

closely related to the back pain and diabetic condition of the patient. Use of Glyburide which is

always accompanied by proper diet and exercise was a good move because Glyburide helps in

CASE ANALYSIS 3

blood sugar level control therefore ideal for people with diabetes as in the case of the patient

(Searle et al., 2015). On the other hand, Lisinopril also helps with treatment of high blood

pressure a condition experienced by the patient and in turn prevents strokes and kidney

problems. It can also treat heart failure and other heart-related issues; hence, its use by the patient

was also very ideal since the patient suffers from blood pressures which also most cases affect

the heart (James, Oparil, Carter, Cushman, Dennison-Himmelfarb, Handler, & Smith, 2014).

Coumadin 6 also as one of the medications used by the patient is a medication for

treating blood clots such as deep vein thrombosis-DVT a condition also suffered by the patient

its use was therefore not bad but ideal for her health control (Itz, Geurts, Kleef & Nelemans,

2013). Use of creatin by the patient was also good as creatin being a nitrogenous compound

assists in many metabolic processes in the body and therefore can help in reducing fatigue

experienced by the patient (Searle et al., 2015). It results in the production of high-energy

adenosine triphosphate which can help in reducing high concentration of blood within the body

of the patient. Therefore, the use of creatin will impact positively by reducing the effect of

diabetes on the patient (James et al., 2014). The patient also used Kava Kava which is a

supplement, and an excellent intoxicating agent; hence, could help the patient by relieving the

pain and cleaning the blood.

In this case, looking into the side effects of the medications that were applied by the

patient if in any case could lead to the back pain, for example, Coumadin could only lead to

nausea, vomiting, stomach pain, bloating and loss of appetite (Itz et al., 2013). Lisinopril could

lead to a cough, depressed mood, dizziness, nausea and mild skin itching. Coenzyme Q10 is

accompanied by side effects involving stomach pain, vomiting, diarrhea, and loss of appetite

(Searle et al., 2015). From the side effects of the recent medication by the patient is evident they

CASE ANALYSIS 4

could not lead to back pain. Therefore, the back pain may be another serious health condition

experienced by the patient. It could be an independent illness since the health conditions suffered

by the patient do not show any symptoms associated with the back pain, and therefore the patient

needs a thorough diagnosis and check (James et al., 2014). The recent medications on the patient

are all relevant and suitable for the patient because they treat diabetes, High blood pressure and

Recurrent DVT’s

From the patient conditions, additional information that could be sought would involve

the occupation of the patient and her daily activities to help in ascertaining whether such could

cause the effect on the back (Itz et al., 2013). For example, poor lifting could lead to back pain

and bad posture which could be a methodology for performing some works. The patient could

also be asked whether she is stressed over specific issues of her life associated with trauma and

anxiety because stress mostly can result to back pain (James et al., 2014). The patient could also

tell her history concerning pregnancy because complications in pregnancy can pose a severe risk

to the back of women. Finally, the patient could be asked how she feels during sexual

intercourse, whether she experience increased pain when moving from sitting to standing, past

tumor history, localized pain and tenderness, symptoms which are related to Coccydynia, a

condition which could lead to back pain especially of women of her age (Itz et al., 2013).

Recommendations for managing the condition may involve the use of cold pack every

day. This is to help reduce inflammation, injection of lidocaine and steroid in the area for

relieving the pain since they are numbing agents. Also, activity modification and change in

dietary are considered as important (Searle et al., 2015). The prescription for the patient could be

some painkillers such as a non-steroidal anti-inflammatory drug (NSAID) to relieve the pain as

much details concerning the conditions is looked into in the process of treatment. This could be a

CASE ANALYSIS 5

proper medication for the start since the patient may be suffering from severe fatigue caused by

daily activities (Itz et al., 2013). The patient could also be advised to continue the physical work

out but reasonably explicitly targeting the back. A professional trainer should guide this workout.

The patient would be educated on proper dietary to help her health conditions such as

diabetes and high blood pressure. Adequate dieting would assist in maintaining the blood sugar

level as well as reducing the cholesterol level within the body (Searle et al., 2015). The patient

will also be educated on the relationship between smoking, drinking, and her conditions so that

she might not indulge in alcohol or tobacco. Smoking and alcohol taking are bad habits with

someone suffering from diabetes and high blood pressure because they can worsen the situation

(James et al., 2014). The patient would also be educated on stress management techniques to

help her reduce stress, anxiety, and trauma which are not suitable for a patient who has diabetes

and high blood pressure.

The patient in managing stresses would be encouraged to join groups of the same interest

to learn essential tips for controlling lifestyle diseases. Such groups would help in initiating

group exercises and classes where she could be taught on techniques of strengthening muscles

and improving posture (Searle et al., 2015). The groups could also offer standard treatments in

cases where physiotherapists head them, osteopaths and chiropractors moreover the step of

joining the support group will provide platforms for supports involving cognitive behavioral

therapy (James et al., 2014). All these services from the group will be useful as part of struggling

to cope with the pain. The patient also needs to be educated on the importance of regular

checkups which is very important in monitoring the blood sugar level.

CASE ANALYSIS 6

The plan for addressing the patient`s conditions would not involve any medical

prescription other than the painkillers. The painkillers will help reduce the pain for the moment

together with the lifestyle management which in turn will assist in balancing the blood sugar

level and the high blood pressure (James et al., 2014). After the use of the painkillers and still,

there is experienced persistence on the pain at the back, the patient will be examined further for

example by the use of x-rays to check if there could be broken bones or other skeleton fractures.

This will help locate the problem by proper analysis (Itz et al., 2013). Computed tomography and

magnetic resonance imaging scans may also be used to identify the source of the pain. From the

scanning, the result will give a better and comprehensive direction for further medication to help

in the treatment of the patient (Searle et al., 2015).

Conclusion

In conclusion, the patient could still not be offered proper medication and prescriptions

on the specific problem regarding the back pain because pain is a severe condition that requires

adequate examination and also could be a mild feeling with no significant consequence on the

health of the patient. The pain-relieving medications that have been recommended will likely

help the patient for a while to help determine whether the condition is a severe health problem

whereby if the condition persists then intense examination can be done to know the exact

problem.

CASE ANALYSIS 7

References

Itz, C. J., Geurts, J. W., Kleef, M. V., & Nelemans, P. (2013). Clinical course of non‐specific

low back pain: A systematic review of prospective cohort studies set in primary

care. European journal of pain, 17(1), 5-15.

James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J.,

... & Smith, S. C. (2014). 2014 evidence-based guideline for the management of high

blood pressure in adults: report from the panel members appointed to the Eighth Joint

National Committee (JNC 8). Jama, 311(5), 507-520.

Searle, A., Spink, M., Ho, A., & Chuter, V. (2015). Exercise interventions for the treatment of

chronic low back pain: a systematic review and meta-analysis of randomised controlled

trials. Clinical rehabilitation, 29(12), 1155-1167.

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