Test for this was physical examination and calculation of BMI.
This is a clue the pain results from trauma caused by physical injury on the lower back (Jallo & Vaccaro, 2009). The injury is because of lifting heavy loads at work. To confirm this diagnosis, the ailing described type, location and severity of his back pain. In addition, he also gave the history of his back pain.
Generally, from the patient’s habit evidence exists that he consumes alcohol in excess, during weekends. This evidence is evident by code V11.3. Research work undertaken in the past cites heavy alcohol drinking normally is associated with lower back pain. Alternatively, the numbness and tingling in his right foot toes results from alcoholic neuropathy (Smith & Stahel, 2014). Alcoholic neuropathy results from too much drinking, which can lead to depletion on nutrients such as vitamin E, folate, vitamins B6 and B12, niacin, and thiamine, needed for proper nerve function.
This condition has no known etiology, however, some of its common symptoms comprise tingling or numbness in hands and feet, abnormal pain processing as well as fatigue among others. It is coded 729.1 to mean it includes other conditions with “Myalgia and myositis, unspecified” (Basavanthappa, 2010). Generally, the diagnosis of this condition is based much on how a patient feels, however, blood tests can also be used. Certainly, the patient had these symptoms, thereby acting as a confirmation for the validity of the diagnosis.
The code provided (304.3) for this diagnosis implies that despite the patient being dependent on cannabis, he has not developed psychological dependence because of the use. Researches cite Cannabis dependence also results to pain in the back or limbs. This is because it causes conditions such as osteomyelitis (Buckup, 2011). Cannabis dependence in the patient was confirmed through the Cannabis Abuse Screening Test (CAST).
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