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Module 5 Discussion

I faced no new challenges so far this week, but time management with the patients seemed to get away from me a little. When trying to obtain the necessary information from the patient pertaining to the reason behind their visit, sometimes the patients can get a little off track. A few patients seen early this week were multiple repeat patients, and without the doctor present at the beginning of the visit, there has been a tendency to inquire about my progress. I appreciate that the patients have been accepting of the role I have been playing in their healthcare, but I know that I need to learn to keep them focused and on track. This is something that will be useful the further along in clinicals I go, as well as when I have begun to practice as a licensed APRN. I see my preceptor having the same problems on occasion, especially with patients who are also considered friends outside of the office. He manages to keep a professional undertone when bringing them back around to the point of the office visit. This is something I will be attempting to do more of in my future clinical rotations, if the need arises.

The patient of topic this week was a 64 y/o male who presented to the office with c/o neck and upper back pain for the past 4 weeks. His vitals were: T: 97.8* F tympanic, HR: 68, RR: 16, BP: 130/74 R arm sitting, O2: 100% on RA. Patient stated his pain was presently 5/10, because he had just taken some Tylenol before arriving at the office. He is a horse trainer and has been working hard preparing for upcoming competitions in the Paso Fino arena. He stated that he recalls no direct injury, he believes that his pain comes from overuse. He did explain that the pain he feels in his neck does radiate down his right arm at times, and describes the pain as more of a burning sensation. He does not feel muscular pain, or tightness with these occurrences. On physical examination of the patient, he denies pain or tenderness at the aforementioned areas. He does admit to pain with some limited range of motion with both neck rotation and right shoulder/arm movements. Slight clicking was noted with his right arm rotations. The patient was referred for cervical spine x-rays. A prescription for diclofenac sodium 50mg PO BID with meals, and cyclobenzaprine 10mg PO BID-TID PRN were provided to help alleviate some of his pain. It was recommended that he rest his back and arms for a while, but he just grimaced and shook his head. The patient was educated on the use of both ice and heat to help with his pain.

The differential diagnoses that were considered were for this gentleman were cervical radiculopathy, cervicalgia, and muscle strain. Cervical radiculopathy is when a nerve root in the cervical spine becomes inflamed or damaged (Meyler, 2019). Neurological deficits, like numbness or weakness, may radiate anywhere from the neck into the shoulder, arm, hand, or fingers. The patient can experience pins-and-needles tingling and/or pain, which can range from aches to shocks or burning (Meyler, 2019). Patients with radiculopathy will usually present with unilateral pain, which can be associated with radiation into the ipsilateral arm in a dermatomal distribution (Iyer & Kim, 2016), like this particular gentleman that was seen in the office this week. Cervicalgia refers to literal pain in the neck region that does not spread to other areas, like the shoulder or down the arms (Kandola, 2017). It is usually caused by sudden, sharp pressure on the neck that results in a strain that can cause discomfort. It only occurs in the neck region though and not in other areas, like the arms or lower back (Kandola, 2017). A muscle strain, or pulled muscle, occurs when a muscle is overstretched or torn. It usually occurs as a result of fatigue, overuse, or improper use of a muscle, and a strain can happen in any muscle, but are most common in the neck, shoulder, and lower back (Pietrangelo, 2019).

The plan of care for this patient begins with the x-ray examination, and depending on the findings of that diagnostic test, additional tests can be ordered, including a CT scan and an MRI (Iyer & Kim, 2016). Electrodiagnostic tests can be utilized to see how the nerves are functioning. Electromyography (EMG), can check nerve and muscle function by monitoring electrical activity in the muscles (Meyler, 2019), and nerve conduction studies can check whether the nerves are sending signals at a proper speed. Non-invasive methods of treatment for cervical radiculopathy consists of NSAID medications, immobilization, physical therapy, and steroid injections (Iyer & Kim, 2016). Hopefully this gentleman will find the right combination of therapies that work best to help return him to his normal level of functioning, and he does not continue to aggravate it with his unwillingness to take the time to actually slow down a bit and allow his body time to heal.

References

Iyer, S., & Kim, H. J. (2016). Cervical radiculopathy. Current Reviews in Musculoskeletal Medicine, 9(3), 272–280. https://doi.org/10.1007/s12178-016-9349-4

Kandola, A. (2017, November 13). What is cervicalgia and how is it treated? https://www.medicalnewstoday.com/articles/320001

Meyler, Z. (2019, January 4). What is cervical radiculopathy? https://www.spine-health.com/conditions/neck-pain/…

Pietrangelo, A. (2019, March 7). Muscle strains. https://www.healthline.com/health/strains20