1.What is the patient’s priority problem?

QuestionAnswered step-by-step1.What is the patient’s priority problem?2.What are the subjective and objective signs and symptoms of this problem?3.What important cultural and spiritual value differences should be considered when delivering high-quality care to this patient?4.What other healthcare disciplines would you involve in the patient’s plan of care, and why?5.What other assessments or screening tools should you implement in the care of this patient?PATIENT DESCRIPTIONOmar is a 58-year-old man referred to the pain clinic for treatment of chronic back pain. He is a Somali refugee who has lived in the United States for more than 20 years and is a practicing Muslim. Omar does not wish to take any drugs, as they are frowned upon in his culture, but he makes exceptions when necessary for his health. If the medication is considered to be intoxicating or narcotic, it is haram, or banned by the Qur’an, so in the past he has been unwilling to take opioids for his pain. Omar hopes that the pain clinic can offer him relief in the form of medication or other therapies, because his back pain has become intolerable. Can you help Omar?DATE LOCATION PROVIDER STATUS DESCRIPTION11/23/202114:33 Central Clinic Joshua Galloway, MD Checked InReferral from Dr. Fowler for chronic back pain. First time visit to pain clinic. Alerts DATE & TIME SUBJECT STATUS ALERT TYPE11/23/202114:32 Morphine Active Adverse Reaction/AllergyDATE & TIME SUBJECT STATUS PREVENTION TYPE            Problems See More >> PRIORITY STATUS DESCRIPTION IMMEDIACY DATE OF ONSET PROVIDERControlled Active Hypertension Chronic 06/25/2020 Joshua Galloway, MDFollowing surgery Resolved Deep Vein Thrombosis s/p 05/24/2020 Joshua Galloway, MDLaproscopic Resolved S/P Cholecystectomy s/p 05/17/2020 Joshua Galloway, MDTakes replacement Active Hypothyroidism Chronic 11/20/2019 Joshua Galloway, MDAggrevated by recent singular fall Active Chronic pain due to trauma Chronic 07/31/2019 Joshua Galloway, MD Vitals See More >> TPR B/P O2DATE TEMPERATURE PULSE RESPIRATION BLOOD PRESSURE PULSE OX11/23/202114:47 37 C 80 14 144/64  PAINDATE PAIN11/23/202114:47:15 7GROWTHDATE WEIGHT HEIGHT/ LENGTH WAIST OR HEAD CIRCUMFERENCE BMI11/23/202114:47 61 kg 179 cm     Labs DATE LAB TEST VALUE UNIT ABNORMAL FLAG REFERENCE RANGE11/02/202114:02          CBC with DifferentialHemoglobin (g/dl) 12 g/dl Low 13.5 – 16.5Hematocrit (%) 37 % Low 41 – 50RBC’s ( x 106 /ml) 4.2 ml Low 4.5 – 5.5RDW (RBC distribution width)   ml   < 14.5MCV 82 fL   80 – 100MCH 28 pg   26 – 34MCHC %   %   31 – 37Platelet count 169,000     100,000 to 450,000WBC (cells/ml) 4,900 cells/ml   4,500 – 10,000Segmented neutrophils   %   54 – 62Band forms   %   3 – 5Basophils   %   0 – 1Eosinophils   %   0 – 3lymphocytes   %   24 – 44Monocytes   %   3 – 6CMP (Comprehensive Metabolic Profile)CMP Albumin 4.1 g/dL   3.2 to 5.2Alkaline phosphatase 120 IU/L   44 to 147ALT (alanine aminotransferase) 50 IU/L High 4 to 40AST (aspartate aminotransferase) 42 IU/L High 4 to 37CMP BUN 21 mg/dL High 8 to 25CMP Calcium 9.1 mg/dL   8.6 to 10.2CMP Chloride 98 mEq/L   98 – 107CMP CO2 26 mEq/L   22 to 29CMP Creatinine 0.8 mg/dL   0.6 to 1.5Glucose test 148 mg/dL High 70 to 115Potassium test 4.2 mEq/L   3.5 to 5.0CMP Sodium 138 mEq/L   135 to 145Bilirubin, Total CMP   mg/dL   0.0 to 1.2CMP Total protein 6.4 g/dL   6.0 to 8.3ElectrolytesElectrolytes Calcium 9.1 mg/dL   8.6 – 10.2Calcium, ionized   mEq/L   2.24 – 2.46Electrolytes Chloride 98 mEq/L   95 – 107Magnesium 2.2 mEq/L   1.6 – 2.4Phosphate 5.1 mg/dL   2.7 – 4.5Potassium 4.2 mEq/L   3.5 – 5.2Electrolyte Sodium 138 mEq/L   135 – 145Lipid ProfileCholesterol, total 250 mg/dl High < 200HDL cholesterol 29 mg/dl Low > 35LDL cholesterol 166 mg/dl   < 130Triglycerides 188 mg/dL High < 150OTHER LABSTSH 0.350      Thyroxine.free 1.11      Triiodothyronine.free 3.3      Hemoglobin A1c 6.5 %     Orders See More >> CATEGORY ORDER ITEM FREQUENCY STATUS WHENPrescriptions Methadone Hydrochloride 10 MG Oral Tablet – Dose: 10 mg AS DIRECTED PRN Active 11/23/202115:17Prescriptions Levothyroxine Sodium 0.1 MG Oral Tablet – Dose: 0.1 mg DAILY Active 11/02/202112:08Prescriptions Warfarin Sodium 4 MG Oral Tablet – Dose: 4 mg DAILY Active 11/02/202112:07Prescriptions Ranitidine 75 MG Oral Tablet – Dose: 75 mg BID Active 11/02/202112:07Prescriptions Amlodipine 10 MG Oral Tablet – Dose: 10 mg DAILY Active 11/02/202112:07 Meds See More >> CATEGORY DRUG DESCRIPTION ORDER STATUS FREQUENCYPrescriptions Methadone Hydrochloride 10 MG Oral Tablet – Dose: 10 mg Active AS DIRECTED PRNPrescriptions Levothyroxine Sodium 0.1 MG Oral Tablet – Dose: 0.1 mg Active DAILYPrescriptions Warfarin Sodium 4 MG Oral Tablet – Dose: 4 mg Active DAILYPrescriptions Ranitidine 75 MG Oral Tablet – Dose: 75 mg Active BIDPrescriptions Amlodipine 10 MG Oral Tablet – Dose: 10 mg Active DAILY Date:11/23/2021 15:17Title:Pain Clinic PlanNote:Mr. Bashir, a patient of Dr. James Fowler, has been referred to this pain clinic for evaluation of pain control options. Fowler’s office forwarded the visit data from Mr. Bashir’s last clinic visit, about three weeks ago. This information has been added to this clinic’s medical record for Mr. Bashir. A review of Mr. Bashir’s medications show that he has tried Celebrex in the past, but discontinued it because he felt it did not work to control his pain. Physical therapy was not successful for him. He has tried ibuprofen and felt it worked well with his prescription pain medication. He takes Ranitidine for the occasional stomach upset associated with the NSAIDs and pain medication. As a devout Muslim, Mr. Bashir feels he can handle the pain without having to take strong medications and does not want to consider morphine or other narcotics. He has actually tried morphine in the past and it drastically reduced his pain, but he states he consulted the Qur’an and feels it is haram, or banned, because of it’s intoxicating effects. He stopped taking it immediately. However, his pain is uncontrolled with the current therapy. He says the pain is nearly a 10 at certain times throughout the day. Dr. Fowler recently added gabapentin 300 mg, 1 capsule PO every evening to Mr. Bashir’s treatment plan. He states the gabapentin helps him sleep, but does not significantly reduce the pain.PLAN: After discussion, Mr. Bashir does not plan to fill the hydrocodone/APAP 7.5/325 mg, 1 tablet PO every 6-8 hours PRN pain prescription. I will discontinue this prescription. Continue the gabapentin 300 mg, 1 capsule PO every evening. I recommend starting methadone 10 mg, take 1 tablet PO TID for pain, #30, no refills. Prescriptions given to patient in office. Ibuprofen as needed. Schedule follow-up appointment for next month. Date:11/02/2021 12:02Title:Primary Care VisitNote:HISTORY OF PRESENT ILLNESS: The patient comes in today for his six-month check-up and renewal of prescriptions. He is well-known to me.Patient is a 58 year old African male with uncontrolled pain throughout his lower back and sides with pain that radiates down his legs with numbness and tingling in the extremities. Although he has experienced back pain for a few years due to a car accident, it has recently worsened as a result of a fall. His pain is somewhat relieved when he is off of his feet. He states the pain is the worse in the morning. He has refused narcotic pain medications because of religious reasons. However, his spinal pathology is worsening and the current pain relief plan is no longer clinically reasonable. PAST MEDICAL HISTORY:  Gallbladder surgery  DVT s/p surgery  Hypertension  Hypothyroidism  GERD  Osteoarthritis  Auto accident resulting in chronic lower back pain SOCIAL HISTORY: Lives alone, is not married, has no children. Denies smoking, alcohol and illicit drug use. Drinks caffeinated beverages daily (coffee and soda). Patient is originally from Somalia, came here as a refugee about 20 years ago. He is a practicing Muslim. Believes that all intoxicants are khamr, or forbidden, based on teachings in the Qur’an. FAMILY HISTORY: There is a family history of hypertension and strokes. Patient had 1 sibling that died of a sudden heart attack at the age of 49. CURRENT MEDICATIONS:  Hydrocodone/APAP 7.5 mg/325 mg, 1 tablet po every 6-8 hours PRN pain – has been prescribed but not filled by patient.  Gabapentin 300 mg, 1 capsule po every evening  Miacalcin, 1 spray in alternating nostrils once daily  Amlodipine 10 mg, 1 tablet po daily  Levothyroxine 0.1 mg, 1 tablet po daily  Ranitidine 75 mg, 1 tablet po BID OTC  Warfarin 4 mg, 1 tablet po daily ALLERGIES: Morphine and opioids are not taken for religious reasons REVIEW OF SYSTEMS: Patient denies any recent unintended weight change. No fever, admits to fatigue and tiredness. Denies headache or change in vision or hearing. No nasal congestion, ear ache or sore throat. No cough or shortness of breath. General muscle aches in the lower back, worsened by long periods of standing, of moderate to severe quality 5-8/10. No nausea, vomiting or diarrhea. Normal bowel and bladder patterns, without dysuria. No changes in appetite. All other systems unremarkable. PHYSICAL EXAMINATION:GENERAL: The patient is alert, oriented, in no acute distress.HEENT: PERRLA. EOMI. TMs clear bilaterally. Nose and throat clear.NECK: Supple without adenopathy or thyromegaly. Carotid pulses palpably normal without bruit.CHEST: No chest wall tenderness.HEART: Regular rate and rhythm without murmur, clicks, or rubs.LUNGS: Clear to auscultation and percussion.ABDOMEN: Soft, nontender, bowel sounds normoactive. No masses or organomegaly.EXTREMITIES: Without clubbing, cyanosis, or edema. Pulses within normal limits.NEUROLOGIC: Cranial nerves II-XII intact. Strength, sensation, coordination, and reflexes all within normal limits.MUSCULOSKELETAL: Tenderness to the lumbar and hip region on palpation; limited range of motion with the left hip. With the patient supine, there is some discomfort in the lower back with bent-knee flexion of both hips as well as with straight leg abduction of the left leg. There is some mild discomfort on internal and external rotation of the hips as well. DTRs are 1+ at the knees and trace at the ankles.SKIN: Noted to be normal. No subcutaneous masses noted. DIAGNOSTICS AND LABS:CT scan following MVA: Compound fracture and bulging disk at the L4-5. MRI from 6 months ago shows further degeneration of the L4-5 with stenosis and changes consistent with advanced osteoarthritis with further bulging of the disks at L3-5.Labs: Glucose 148, Hgb A1c 6.5, Total Chol 250, LDL 166, HDL 29, Triglycerides 188. All other labs within normal ranges. ASSESSMENT:Chronic low back pain and sciatica secondary to compound fracture with resulting degenerative osteoarthritis, stenosis and bulging disk PLAN:  Continue current medications  Referral to Dr. Joshua Galloway for pain management      Health ScienceScienceNursingNUR 306Share Question

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