Reference no: EM133396969
Question: Robert is a 76-year-old male who has recently made some comments about a deep aching pain in the central lower back area right down through the right leg. He has been observed shuffling and dragging his right leg more than usual and has had to sit out on some of the physical activities in his program.
Robert has compared the pain in the leg to the feeling of pins and needles and sometimes a mild numbness. The pain tends to flare up on the colder days, where he has taken a longer time to get out of bed. He is quite frustrated and often sad as he enjoys being physical and interacting with others in shared activities.
Robert was employed for over 25 years in a factory which involved lots of heavy lifting, twisting and prolonged standing. An injury sustained to his lower back during his time at the factory impacted his ability to continue with full-time employment. Since that time, he never returned to his pre-injury duties at the factory and remained on WorkCover assistance until they were terminated. The pain in his lower back flared over the years until surgery became the only option in attempt to alleviate the issue.
Robert's medical history note that a CT and MRI scan from over five years ago discovered a multilevel disc bulges in the L2/3 L3/4 L4/5 L5/S1 with neural impingement on the right side. The results display signs of facet joint degeneration suggestive of osteoarthritis.
His physical exercise consists of going for morning strolls around the garden, stretching and indoor bowls. He has been able to go on outings to the local shops to help out with the groceries and assigned to collecting mail out the front twice a week.
His daughter Vanessa and Aldi, an old friend from the factory come to visit Robert often. Vanessa accompanies Robert on some of his outdoor strolls and Aldi likes to get involved with some of the indoor activities with Robert.
What key information has been provided to help you assess his physical status?
Provide at least five ways you could obtain further information on Robert's current condition or medical history.
Provide at least five types of documentation you could use to review his physical health.