3c. Feedback and Synthesis Improvement Plan
D027 Treatment Plan
Samthia A. Lenox
Patient: Mr. Tanner Bailey, a 30-year-old transgender male.
Chief Complaint: Present to clinic for lower back pain. He stated that he had been having back
pain for over thirteen weeks.
Current medications include a 100-milligram testosterone injection and 1000 milligrams of
acetaminophen every six hours.
Diagnostic Testing
The diagnostic methods used to diagnose back injuries are MRI (magnetic resonance imaging),
CT scan (computed tomography), ultrasound, X-ray, and PET Scan (positron emission
tomography). Utilizing these diagnostic tools allows for a detailed description of the location of
the area causing the pain. The imaging results will determine the treatment plan for Mr. Bailey's
back pain. Ultrasound and X-ray will be the first diagnostic tests ordered to locate the inflamed
area causing the pain.
Medications
Medications that are utilized first are NSAIDs (Sayed & Callahan, 2023). Mr. Bailey was
prescribed ibuprofen 800 mg tablets to be taken by mouth every eight hours for pain relief.
Educated on the maximum daily dose of ibuprofen is 3200 mg. Informed that there is no antidote
for ibuprofen. Educated on the effects of an overdose of ibuprofen can lead to seizures, apnea,
hypertension, and hepatic and renal dysfunction. (Ngo & Bajaj, 2024) Muscle relaxants can also
be ordered if ibuprofen does not help relieve pain. Encourage the patient to take medication with
food or milk to prevent gastrointestinal upset. Encourage the patient to watch for signs of
bleeding, which include bruising, bleeding gum, and blood in stool. (Ghlichloo & Gerrieta,
2023). Instructed not to drink alcohol while taking this medication and to take medication as
prescribed. He reported having one to two monthly drinks when he is out with friends.
Non-pharmacological
Non-pharmacological treatment includes hot and cold therapy, which can be done in the home.
Mr. Bailey was informed to rotate hot and cold treatments and not exceed twenty minutes with
both therapies. Mr. Bailey was also referred to physical therapy to help strengthen back muscles.
Therapy will teach Mr. Bailey, proper body mechanics, when lifting, pulling, or sliding large
objects. Mr. Bailey was educated on following up with all scheduled appointments. Mr. Bailey
had delayed care for back pain due to him being a transgender male. He expressed that previous
provider had a phobia of transgender individuals Encouraged to follow regimen as ordered. Mr.
Bailey was encouraged to use proper posture and body mechanics when lifting heavy objects and
bending to prevent further injuries. (Sayed & Callahan, 2023)
D027 Treatment Plan
Samthia A. Lenox
Patient: Mr. Tanner Bailey, a 30-year-old transgender male.
Chief Complaint: Present to clinic for lower back pain. He stated that he had been having back
pain for over thirteen weeks.
Current medications include a 100-milligram testosterone injection and 1000 milligrams of
acetaminophen every six hours.
Diagnostic Testing
The diagnostic methods used to diagnose back injuries are MRI (magnetic resonance imaging),
CT scan (computed tomography), ultrasound, X-ray, and PET Scan (positron emission
tomography). Utilizing these diagnostic tools allows for a detailed description of the location of
the area causing the pain. The imaging results will determine the treatment plan for Mr. Bailey's
back pain. Ultrasound and X-ray will be the first diagnostic tests ordered to locate the inflamed
area causing the pain.
Medications
Medications that are utilized first are NSAIDs (Sayed & Callahan, 2023). Mr. Bailey was
prescribed ibuprofen 800 mg tablets to be taken by mouth every eight hours for pain relief.
Educated on the maximum daily dose of ibuprofen is 3200 mg. Informed that there is no antidote
for ibuprofen. Educated on the effects of an overdose of ibuprofen can lead to seizures, apnea,
hypertension, and hepatic and renal dysfunction. (Ngo & Bajaj, 2024) Muscle relaxants can also
be ordered if ibuprofen does not help relieve pain. Encourage the patient to take medication with
food or milk to prevent gastrointestinal upset. Encourage the patient to watch for signs of
bleeding, which include bruising, bleeding gum, and blood in stool. (Ghlichloo & Gerrieta,
2023). Instructed not to drink alcohol while taking this medication and to take medication as
prescribed. He reported having one to two monthly drinks when he is out with friends.
Non-pharmacological
Non-pharmacological treatment includes hot and cold therapy, which can be done in the home.
Mr. Bailey was informed to rotate hot and cold treatments and not exceed twenty minutes with
both therapies. Mr. Bailey was also referred to physical therapy to help strengthen back muscles.
Therapy will teach Mr. Bailey, proper body mechanics, when lifting, pulling, or sliding large
objects. Mr. Bailey was educated on following up with all scheduled appointments. Mr. Bailey
had delayed care for back pain due to him being a transgender male. He expressed that previous
provider had a phobia of transgender individuals Encouraged to follow regimen as ordered. Mr.
Bailey was encouraged to use proper posture and body mechanics when lifting heavy objects and
bending to prevent further injuries. (Sayed & Callahan, 2023)
