The Carlotta Russe iHuman Case Study offers an in-depth examination of a complex clinical scenario, designed to enhance your diagnostic and treatment skills. The case involves a 65-year-old Caucasian female, Carlotta Russe, who presents with moderate low back pain. This article will explore her history, physical examination, problem statement, differential diagnosis, and provide insights into the management of her condition.
Table of Contents
Carlotta Russe iHuman Problem Statement
Carlotta Russe is a 65-year-old Caucasian female who presents to the clinic with complaints of moderate low back pain that began two days ago. The pain started after moving heavy tables at work and radiates into her right buttocks and down her right leg. She describes the pain as sharp, constant, and rated at 7/10. Carlotta reports that the pain worsens with activity, is not relieved by anything, and even awakens her from sleep. She has not taken any medication to treat the pain. She denies bowel or bladder dysfunction, as well as numbness or tingling.
The physical examination reveals an inability to bend at the waist, limited range of motion (ROM) in the right lower extremity (RLE), slightly diminished sensation, and hypo reflexive patellar deep tendon reflex (DTR). Her past medical history (PMH) is significant for osteoporosis, with her last bone density test over a year ago showing a score of -2.5. She also has chronic asthma, currently managed with a prednisone taper, and a history of surgical menopause at age 42, as well as hypertension (HTN).
Carlotta Russe iHuman Differential Diagnosis
Given Carlotta’s clinical presentation and history, several differential diagnoses should be considered:
- Lumbar Disc Displacement (Disc Herniation) – M51.27
This diagnosis is highly likely given the acute onset of low back pain after moving heavy tables, coupled with the physical exam findings. Carlotta’s inability to bend at the waist, limited ROM, unrelieved pain, and diagnostic imaging support the conclusion of L4/L5 herniated nucleus pulposus with associated right-sided L4 radiculopathy. The pain radiating into the right buttock and leg, along with hypo reflexive patellar DTR, are classic signs of this condition. - Lumbago with Sciatica, Right – M54.41
Another likely diagnosis is lumbago with sciatica. The acute injury at work, coupled with worsening pain during movement and physical exam findings, strongly suggest this condition. The sharp, constant pain radiating down the right leg, limited ROM, and hypo reflexive patellar DTR are consistent with lumbago complicated by sciatica. - Lumbar Spinal Stenosis
Though less likely than the above two, lumbar spinal stenosis could be considered given Carlotta’s age and chronic nature of her back issues. The symptoms of radiating pain and limited ROM may overlap with spinal stenosis, particularly in elderly patients. However, the acute onset following an injury makes this less probable. - Osteoporotic Vertebral Fracture
Considering Carlotta’s history of osteoporosis, an osteoporotic vertebral fracture cannot be ruled out. The sudden onset of pain after heavy lifting, combined with her osteoporosis history, could suggest a compression fracture. The absence of bowel or bladder dysfunction decreases the likelihood of severe neurological compromise. - Myofascial Pain Syndrome
This condition could be considered given the muscle strain from moving heavy tables. However, the radiating pain and neurological findings make this less likely.
Carlotta Russe iHuman Diagnosis and Management Plan
Based on Carlotta’s presentation and physical exam, the most likely diagnosis is L4/L5 herniated nucleus pulposus with associated right-sided L4 radiculopathy. The management plan for Carlotta should focus on pain relief, inflammation reduction, and preventing further injury.
Carlotta Russe iHuman Plan of Care
- Medications:
- Initiate nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management.
- Consider short-term use of oral corticosteroids if NSAIDs are ineffective.
- Prescribe a muscle relaxant if muscle spasm is present.
- Activity Modifications:
- Advise Carlotta to avoid activities that exacerbate her pain, such as heavy lifting or prolonged sitting.
- Recommend physical therapy focused on strengthening the core muscles and improving flexibility.
- Diagnostic Imaging:
- Order an MRI of the lumbar spine to confirm the presence and extent of disc herniation.
- Consider a bone density test to assess the current status of her osteoporosis.
- Referral:
- If symptoms persist or worsen, refer Carlotta to an orthopedic specialist or a spine surgeon for further evaluation and possible intervention.
- Follow-Up:
- Schedule a follow-up appointment in two weeks to assess the effectiveness of the treatment plan and adjust as necessary.
- Monitor Carlotta’s response to treatment and her compliance with activity modifications and medications.
In conclusion, the Carlotta Russe iHuman Case Study offers a comprehensive overview of a complex clinical scenario involving acute low back pain with radiculopathy. By carefully considering the differential diagnoses and implementing a targeted treatment plan, healthcare providers can effectively manage Carlotta’s condition and improve her quality of life.
Must Read: