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48 Yr Old Man Presents to Er Stating My “Left Lower Leg Is Killing Me.”

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Submitted By zodnmic
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48 yr old man presents to ER stating my “left lower leg is killing me.” Patient has been in pain for two days. When asked when the pain started PT states “while I was playing water Volleyball, I felt a pop in my leg, I thought maybe I just strained a muscle but it feels like someone hit me in the back of the leg with a bat, I can’t even walk on my leg.”
Upon visual evaluation the leg is swollen and blue in color. Nurse is observing swelling, bruising, and alignment of the two legs. A Thompson test can be used to the severity of the injury.
The tender area felt boggy to palpation and a gap was found. Both feet and ankles felt normal, although a non-tender calcaneus was found. The patient had a capillary-refill time of less than two seconds and no neurovascular deficit. The left ankle had normal dorsiflexion and plantar flexion, but there was active resistance on plantar flexion in the right ankle. Passive inversion and eversion movements were normal with no laxity and endpoints were firm.

Initial diagnosis was a ruptured Achilles tendon in the right leg and this was confirmed by ultrasonography. Radiography was not indicated.

The patient’s case was discussed with an orthopaedic registrar by telephone. The patient’s limb was then placed in equinus cast, in which the ankle is flexed to between 40° and 60°, and plaster of Paris was applied.

To ensure the patient’s psychosocial needs were met, and that he had a realistic expectation of rehabilitation and long-term care, potential complications related to his cast and medication were explained to him. In addition, he was advised to undertake physiotherapy before returning to sport and not to take fluoroquinolones to prevent re-rupture.

The patient was then prescribed naproxen 500mg, to be taken orally twice a day, and discharged home.

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Mrs. Jones presents to her primary care office with complaints of sharp pains in her wrists, forearms and fingers. The physician diagnoses her with carpal tunnel syndrome.

ASSESSMENT: I would ask the patient to describe why she came to the office and how long she has been having these symptoms. I would ask what the pain feels like (burning, cramping, sharp, etc), if it is continuous or intermittent, if it is radiating and if there is anything that makes it better or worse. I would ask a thorough health history as well as any medications or supplements she takes. Her occupation and hobbies are important to note.

HISTORY: A history of injuries or continuous stress on her muscles (a job where she types on a computer every day for example) might be associated with this symptom.

RISK FACTORS: Risk factors for carpal tunnel syndrome can be any of the following: Past wrist fracture or injury, female, diabetes, alcoholism, nerve damage, rheumatoid arthritis, pregnancy, menopause, obesity, thyroid disorders, kidney failure, occupational hazards (working with vibrating tools or in assembly line,repetitive flexing, computer work).

EXAM: For Mrs. Jones' physical exam, I would explore the 5 "P"s related to her symptoms (pain, pulse, pallor, paresthesia and paralysis.) I would also use the technique of inspection (inspecting all skin surfaces and muscles), palpation, range of motion (on both upper and lower extremities) and muscle strength. I would mostly focus on the feeling and pain sensations she is experiencing in her forearms, wrists and fingers. It is also a good idea to ask about any pain in her elbows (ulnar nerve) during the assessment.

EDUCATION: I would teach Mrs. Jones about any medications she is being started on (sometimes NSAIDs or corticosteroids are prescribed), how to take them and when to take them. If wrist splinting is being used, I would teach her how to apply the splints and for how long to wear them. If the physician decides that surgery is the best option, I would ask her pre-operative questions and explain the pre-op and post-op process. It is important she understands the recovery period and what she can do to aid her recovery from surgery.

NURSES NOTE: Patient NJ presented to the office today complaining of sharp, tingling pains radiating from her fingers up her wrists and forearms bilaterally. She states this type of pain started mildly one year ago and has progressively gotten worse. She now rates the pain a 7/10 with the pain triggered by holding a grip on an object (hair dryer, pan handle, pen, etc.) The pain is relieved by resting her hands and arms. She takes ibuprofen for the pain and uses heat compresses. She works as a secretary 40 hours per week. She has medical history of diabetes and is currently in menopause. Upon assessment, her radial pulses are 2, skin is warm/dry/pink, she has intermittent numbness in her fingers and wrists and no paralysis.

JOURNAL ARTICLE: The article Management of patients with carpal tunnel syndrome in Nursing Standard reviews the anatomy behind this syndrome, the prevalence and characteristics of carpal tunnel, studies done on the condition, causes, management and post-operative care. There are great diagrams for the visual learner in this article. It is a good article to read for an "all-inclusive" journey through carpal tunnel syndrome from start to finish. It is in the orthopedic nursing section.

Carpal tunnel syndrome. (2011, February 22). Mayo Clinic. Retrieved October 15, 2013, from

Walker, J. A. (2010). Management of patients with carpal tunnel syndrome. Nursing Standard, 24(19). Retrieved October 15, 2013, from…...

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