Sample Case Study In Nursing Care
DOI: 7/12/2014. The patient is a 39-year old male forklift driver who sustained a work-related injury to his lower right leg after it was crushed when he was knocked over by a forklift. As per OMNI entry, the patient is Permanent and Stationary as of 10/16/2015 with future medical care to include pain management medications, as well as durable medical equipment in forms of shoes and inserts.
Per progress report dated 5/24/16, patient was prescribed with ibuprofen, Lyrica, Norco and Lidoderm patch.
Based on the progress report dated 06/24/16, the patient continues to have persistent right foot and ankle pain, rated as 9/10. He describes his pain as constant aching, sharp and shooting to throbbing pains throughput the heel area, and into the foot with pins and needles into the heel area. Pain is ongoing and consistent, increased with activity l2evel. He continues to work 12 hour shifts and is difficulty and increase his pain level. He did just receive the shoe inserts and has been wearing …show more content…
Dysesthesia is noted to the right heel area. Dorsiflexion and plantar flexion is less than 10 degrees. Callus formation is noted on the right medial forefoot. Antalgic gait is noted. He ambulates without weight bearing, due to heel pain. Strength is 4+/5 with right plantar flexion and dorsiflexion. Patient is also psoitve for reflux and depression
Diagnoses are right heel pain; right heel neuropathic pain; and possible complex regional pain syndrome.
He was advised to continue with medications, home stretching and exercise program.
He was given a prescription for Voltaren gel 1%, to be applied 2 g to the affected ankle 4 times daily, Lyrica 50 mg 1 tablet at bedtime for neuropathic pain, Norco 10/325 mg 1 tablet every 6 hours as needed for breakthrough pain and Lyrica 600 mg 1 tablet every 12 hours as needed for inflammation and pain. Follow-up plan is in 5-6
Per progress report dated 5/24/16, patient was prescribed with ibuprofen, Lyrica, Norco and Lidoderm patch.
Based on the progress report dated 06/24/16, the patient continues to have persistent right foot and ankle pain, rated as 9/10. He describes his pain as constant aching, sharp and shooting to throbbing pains throughput the heel area, and into the foot with pins and needles into the heel area. Pain is ongoing and consistent, increased with activity l2evel. He continues to work 12 hour shifts and is difficulty and increase his pain level. He did just receive the shoe inserts and has been wearing …show more content…
Dysesthesia is noted to the right heel area. Dorsiflexion and plantar flexion is less than 10 degrees. Callus formation is noted on the right medial forefoot. Antalgic gait is noted. He ambulates without weight bearing, due to heel pain. Strength is 4+/5 with right plantar flexion and dorsiflexion. Patient is also psoitve for reflux and depression
Diagnoses are right heel pain; right heel neuropathic pain; and possible complex regional pain syndrome.
He was advised to continue with medications, home stretching and exercise program.
He was given a prescription for Voltaren gel 1%, to be applied 2 g to the affected ankle 4 times daily, Lyrica 50 mg 1 tablet at bedtime for neuropathic pain, Norco 10/325 mg 1 tablet every 6 hours as needed for breakthrough pain and Lyrica 600 mg 1 tablet every 12 hours as needed for inflammation and pain. Follow-up plan is in 5-6