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Corticotoid Attack Case Study Nursing

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DOI: 5/31/2016. Patient is a 44-year-old male warehouse operator who sustained injury to his right elbow when he struck his right upper extremity on a metal crate. Per OMNI, he was initially diagnosed with contusion of the right elbow. Per the progress report dated 07/20/16, a corticosteroid injection was provided into the right elbow. Based on the progress report dated 08/22/16, the patient continues with on and off, achy and sharp stabbing right elbow pain and stabbing pain in the right wrist. His pain varies in degree of frequency and intensity depending upon activities and prolonged repetitive use. Extension of the right arm aggravates his elbow and repetitive flexion/extension movement aggravates his pain. Twisting and turning jar …show more content…

He was given a wrist brace the patient wears on the right wrist. The patient was then given a cortisone injection into his right elbow about one month later with some benefit. He was continued temporarily totally disabled. Currently, patient is taking Aleve as needed. On examination, there is tenderness at the right lateral epicondyle. Right elbow range of motion shows pronation and supination of 80 degrees, both with pain. There is also pain with extension. IW was diagnosed with right elbow lateral epicondylitis and right elbow arthralgia. He was given a prescription for Voltaren gel 1% 3-100 mg with 3 refills, to be applied 2 grams to the area, 4 times daily. Treatment plan includes ice/heat application to areas of discomfort as needed, home exercise program (HEP), over-the-counter nonsteroidal anti-inflammatory and analgesics as neded, PT to the right elbow 2 time s a week for 6 weeks, platelet rich plasma injection for the right epicondyle with ultrasound guidance for needle placement, as the patient has failed bracing and 1st cortisone injection. Patient will follow-up in 4 weeks. Per verification from the provider’s office, they are only requesting for a platelet rich plasma kit, not an injection. Current request is for This is 1 out of 4

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Per medical report dated 06/30/15, patient presented for low back pain with left anterior leg pain. He has not tried PT or injections. He does have weakness in the left leg. At times, he is unable to put pressure on the left side.

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Elbow Injuries Tennis Elbow: This injury is called tennis elbow due to the problem being significant for tennis players. Tennis Elbow is caused by the overuse of the arm, forearm and hand muscles. The abrupt or subtle injury off the muscle or tendon area around the outside of the elbow, is a major contributor to the pain that people who have tennis elbow receives. The area where the muscles and tendons of the forearm attaches to the outside of the bony area (lateral epicondyle) is where it is affected. Tennis players mostly receives this injury on their dominant arm but it can occur or either arm.

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At this time, there is chronic pain both with activity and at rest, with marked loss of motion.

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The phases included pain reduction, developing scapular stability, increasing ROM, muscular strengthening, and focusing on sensory motor training. The sensitivity was 76% and the ICC was listed as 0.41. The average Visual Analogue Scale for pain scores decreased from 6.25 to 0 while the ASORS test improved from the average 71.5 points to 90.5 points. A score of 90 to 100 points was considered to be an excellent result.4 To assess appropriate outcome measures, the Upper Extremity Functional Index (UEFI) and goniometric ROM, was completed at Derek’s initial evaluation and on his final day of treatment.

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The report notes a prior shoulder surgery in 2002, on the right shoulder. An X-ray was done of the left shoulder, which did reveal degenerative changes in the acromioclavicular joint, as well as post-surgical changes, and degenerative changes on the right side in the acromioclavicular joint. The applicant was subsequently referred to an orthopedic surgeon, Dr. Peter Simonian. An MRI of the right shoulder was conducted on April 10, 2015, which noted tendinopathy of the supraspinatus and infraspinatus tendons. No tear of the rotator cuff, but a superior labrum anterior to posterior tear extending to the posterior labrum, as well as post-surgical changes.

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The first three days the elbow will be immobilized by hinged braces, plaster cast, and slings at 90 degrees. The pain can be managed by NSAIDS’s, Ice, and IFC, and the athlete should avoid passive elbow ROM. After three days, the athlete will be positioned approximately “30-90 degrees of flexion” in a hinged braced for four to two weeks (Houglum, 2005). The athlete is instructed to increase extension by five degrees and ten degrees of flexion each week. Active movement will be initiated with slow, gradual shoulder isometrics and grip strength.

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This week I have seen a very interesting case at the Vine Clinic. A 17-year-old female who came in with her mother had a chief complain of joint pain and a severe headache uncontrolled by Ibuprofen. She has recently seen in the ER for joint pain. I observed my preceptor conducted a thorough history and physical exam. She started joint pain on the right side of her knee and then the pain migrated to the left side of her body and affecting all the major joints.

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He reports that Dr. Shah told him to increase his medications for a few days. He said that since his pain was so severe he did not decrease the medications back down and is almost out of medications. He also reports he is not able to stand for very long, spending most of his time in bed.

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Palpation reveals + 3 tenderness at the distal radioulnar joint of the wrist right, and the triangular fibrocartilage complex. Tinel's sign is positive and Phalen's sign is positive at the carpal tunnel. Patient has a positive EMG/NCV dated 12/17/14 for moderate to severe damage to the median nerve at the left wrist, consistent with right carpal tunnel syndrome. Patient walks with a gait, favoring the left leg.

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Colombel et al (2010) provided that nurses are required to modify the planning process to the needs of individual patients and the implementation of MACROS can enable the nursing staff to ensure that plan is considering the measurability, achievability, realistic aspects, written results, and focused on the client. It was found that the pain of Allen was due to the causes leading to Crohn’s disease. The inflammation was planned to be treated with the intravenous hydrocortisone, which is the anti-inflammatory drug and prescribed for reducing the inflammation. Fisher et al (2008)further reflected that the initial doses of this planned drug are required to be forty to sixty grams on daily basis and she was prescribed for forty grams. Hill (2015) reflected that once the reduction in the pain is achieved the doses are reduced leading to

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During assessment, she stated that she usually experiences pain intermittently on the left side of her body, as well as her lower back and that her hip feels dislocated. The patient was not sure of how to rate her pain on a scale with 1 being the lowest and 10 being the highest, however, she stated that the pain worsens with movement and the pain is not relieved whenever she receives her medication. The medications given to her are: panadine and voltaren. The patient also states that there are no associated factors with the pain. Inadequately managed pain can lead to adverse physical and psychological patient outcomes for individual patients and their families.

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