ASSESSING MUSCULOSKELETAL PAIN NURS 6512
ASSESSING MUSCULOSKELETAL PAIN NURS 6512
A 15-year-old Caucasian male Justin Timberland presents to the clinic with reports of dull pain in both knees. He states sometimes one or both knees click, and he describes a catching sensation under the patella.
To begin my assessment of my patient’s knee pain, I’ll approach the interview initially by utilizing “a useful framework to differentiate whether the limb pain involves symptoms that are caused by musculoskeletal injury, musculoskeletal or joint disease, or systemic disease, or a combination of factors. Pain can result from direct reaction in tissues, secondary reaction in adjacent tissues, or reaction from a proximal or distal lesion, or from organs such as the heart or kidney”.(Dains,2019.p.1.).knowing this information, I decided to start with a Focused history, where I would begin by asking the patient questions such as, does he have any of the common childhood bone diseases, that would make him prone to bone injury or pain, i.e. Osteogenesis Imperfecta or as commonly known as brittle bone disease, as it is usually diagnosed at birth as a bone is broke during the delivery process, from the fetus traveling down the bony structures of the birth canal. Next, I will ask him if the pain if from an injury? If it was an injury, how did the injury occur? Is this a new injury, or is this an old injury that has recurred? And finally, I will ask him to state his level of pain, on a scale from 0-10, with 0 being the least pain, and 10 being the worst pain?
According to research, the location of pain, has a strong influence on a patient’s functional status, my next step will be to differentiate his knee pain, corresponding to a research article based on elderly and knee pain, “the most common knee patterns are tibiofemoral only pain (62%), followed by patellofemoral only pain(23%), and combined pain (15%). The combined pain pattern was associated with odds of reporting pain, symptoms, sports or recreational activity limitations and lower knee-related quality of life compared to either isolated knee pain patterns, after adjusting for demographics and radiographic disease severity. The research article also mentioned using a “knee map” on the participants, so the participants can classify their pain into three categories of localized, regional, or diffuse.”.(Farrokhi,2016.p.).The medical assessment is a vital means to correctly diagnose and treat knee pain and problems “ many maneuvers are available to rule out the type of stability and test the knee structures involved. All tests can be divided in 4 groups: stress tests, slide tests, pivot shift(jerk) tests, and rotational tests.
1.Stress Tests- the standard stress tests include valgus (abduction), and varus (adduction) tests; additionally, Cabot maneuver is a commonly used stress test. The key point in performing these tests is taking care not to perform them carelessly. The test should be conducted at 30 degree flexion, rather than in full knee extension: by flexing the knee all tendinous structures and posterior capsule are released allowing to evaluate the MCL and LCL isolated.
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2.Bohler’s test- a varus and a valgus stress are applied to the knee: pain is elicited by compression, of the tear.
- Squat test, duck walking test Thessaly test consist in several repetitions of full weightbearing flexions on the knee, in various positions (squatting, walking in full flexion, and at a 5 and 20 degree flexion, respectively).
4.Merke’s test is like Thessaly test performed in a weightbearing position: pain with internal rotation of the body produces an external rotation of the tibia and medial joint line pain when medial meniscus is torn. The opposite occurs when lateral meniscus is torn.
- Helfet’s test, in this test, the knee is locked and cannot c externally while extending, and the Q angle cannot reach normality with extension.
6.In test, the patient is asked to sit in Turkish position, thus stressing the medial joint line: if the position raises pain, the test is positive for a medial meniscal lesion.
7.In Steinmann’s first test, the knee is held flexed at 90 degree, and forced to external rotation, then internal rotation: the test is positive for medial meniscal tear if raises pain upon externally rotating, while it is positive for lateral meniscal tears in case of pain during internal rotation.
8.Apley’s (grinding) test is conducted with the patient prone, and the knees flexed to 90 degrees, then the leg is twisted and pulled, then pushed. If pain is only felt while pushing, a meniscal lesion is diagnosed, while if no difference between distraction and compression is detected, a chondral lesion is more likely”.(Rossi,2011.p.5.). In addition to the physical exams, there are some diagnostic tests physicians use to gather information about the patient’s condition. Some of the tests that may be ordered are a Computed Tomography scan, as the scanner circles the body, and the cross-sectional images of the knee, will allow the physician to better pinpoint the place of injury, a Magnetic Resonance Image MRI, uses a powerful magnetic field, radio waves, and a computer to create in-depth images of the structures inside the knee joint, an Arthroscopy, is a surgical procedure, where a small camera is inserted into the knee joint through tiny cuts to look for problems within the knee joint, or a knee x-ray, that can locate the origin of pain, deformity, swelling of the knee, it can also display dislocated joints or broken bones.
(DDX)
1.Rheumatoid arthritis.
- Gout.
- Baker’s cyst.
- Meniscal tear
5.Patellofemoral pain syndrome.
References
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby Retrieved August 1,2022 from
Farrokhi S, Chen YF, Piva SR, Fitzgerald GK, Jeong JH, Kwoh CK. The Influence of Knee Pain Location on Symptoms, Functional Status, and Knee-related Quality of Life in Older Adults with Chronic Knee Pain: Data from the Osteoarthritis Initiative. Clin J Pain. Retrieved August 2,2022 from doi: 10.1097/AJP.0000000000000291. PMID: 26308705; PMCID: PMC4766069.
Rossi R, Dettoni F, Bruzzone M, Cottino U, D’Elicio DG, Bonasia DE. Clinical examination of the knee: know your tools for diagnosis of knee injuries. Sports Med Arthrosc Rehabil Ther Technol. Retrieved August 4, 2022, from doi: 10.1186/1758-2555-3-25. PMID: 22035381; PMCID: PMC3213012.
Back pain
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Back Pain
Subjective Data
Back pain can be experienced in various ways, including stinging, muscle spasms, or achy pain (Aish et al., 2021). Back pain is the most common musculoskeletal condition and is often associated with potential or actual tissue damage (Ball et al., 2015). The low back/lumbar spine is a strategic structure of interconnected bones, nerves, ligaments, joints, and muscles that work harmoniously to provide strength, support, and flexibility. The complexity of the structure makes it more vulnerable to repetitive injury, blunt impact, or sudden stress due to lifting or pulling. Below is a list of subjective data of interest.
Chief Complaint: Back pain
Location: Lower back
Onset: One month ago
Character: At times, the pain radiates to his left leg
Duration: Ongoing pain. the health care professional will assess how long did the pain start
Associated Factors: Will enquire such as headache, chills, and dizziness.
Relieving Factors: Will enquire what alleviates the pain, such as position, or a massage
Severity: I will enquire how bad is the pain using the numeric tool assessment, with “0” being no pain and “10” being the worst pain
Family History: I will enquire; it is very important to ask about the family history. Doing this will help determine if genetics is involved.
Social history: Will inquire about drinking or smoking habits and assess if the patient is taking illicit drugs. Also, the nurse will ask about the kind of work the patient is doing.
Past surgical history: None; I will assess past surgical history
Timing: The healthcare professional will enquire specific time
Was the pain gradual or sudden: I will enquire how the pain started and also assess if the pain is sudden or gradual
Medications: as a nurse practitioner, its important to assess what kind of medication the patient has been taking for the pain and also assess if the medication is working
Endocrine: will enquire
Hematologic: I will assess if the pain has a history of blood clots, bleeding disorders, bone marrow, lymph node and spleen
Objective Data
Physical Assessment:
Vital signs: Key signs to consider in this context include blood pressure, respiration, heart rate, temperature, pulse oximetry, weight, and height.
Neurological: The key metrics to be assessed here entail clearness of speech, vision changes, patient alertness, judgment, and facial drooping.
Lungs/Chest: Examine tachypnea, clearness of bilateral breath sounds, and whether the lungs expand symmetrically.
Skin: Explore the skin paleness, ashen, or cyanosis. Also, look for tainting, tears, and whether the skin is dry/warm.
Musculoskeletal: Examine the evidence of trauma in the affected area, radiation of lower back pain, and the relationship between pain and flexion, twisting, and extension. It is also imperative to assess whether there is reduced mobility due to pain.
Abdomen: Examine key characteristics such as softness, tenderness, presence of bowel sound, and activeness in all four quadrants.
Peripheral vascular/Heart: Here, we shall look at whether the heart rate rhythm is regular, the rate at which capillary refill in all extremities, whether S1 and S2 sounds are heard, and finally, the palpable and strength of peripheral pulses.
Diagnostic Tests:
Assess inflammations makers or infections through blood count.
Check erythrocyte sedimentation rate
Perform HLA-B27 to examine the white blood cells.
Perform MRI of the lumbar spine.
Perform Computerized Tomography (CT) cervical spine.
Perform an X-Ray of the lumbar spine.
Assessment
Differential Diagnosis:
Lumbar Spinal Stenosis (LSS) is the narrowing of the spinal canal and imposes pressure on the nerve extending from the spinal cord to the muscles (AANS, 2022). It can either be due to congenital abnormalities, primary or acquired, secondary. It is often attributed to degenerative changes in older persons. Degenerative LSS can involve lateral recess, central canal, foramina, or a combination of these locations. Neurogenic claudication is the primary symptom of LSSS and refers to leg symptoms holding the groin, buttock, and anterior thigh. Leg symptoms can comprise heaviness, fatigue, and paresthesia. The symptoms are usually symmetrical, bilateral, or unilateral.
Lumbar Disc Herniation (LDH): It is often referenced in the context of low back pain. The Intervertebral disc comprises the outer Annulus Fibrosus (AF) and inner Nucleus Pulposus (NP). The NP comprises type II collagen, which makes up to 20% of its overall dry weight. It is maintained in the center of the disc by AF, whose concentric type 1 fiber makes up 70% of its dry components. The narrowing of the thecal sac’s space in LDH can be due to extrusion of NP through AF, protrusion of disc through AF, but maintaining continuity with disc space. However, there can also be a complete loss of continuity with the disc space or sequestration of a free fragment. LDH’s common signs and symptoms include sensory abnormalities and radicular pain (Al Qaraghli & De Jesus, 2021). Its predisposing factors include Axial Overloading and dehydration, while 75% is hereditary.
Sciatica: Entails the pain radiating through the sciatic nerve’s path. Sciatica, also known as radiculopathy, is primarily caused by undue pressing on the sciatic nerve. The pressing typically travels via the buttocks and extends to the back of the leg. Persons with sciatica often feel burning low back pain or shock-like impact combined with the pain through the buttocks and down the leg (Ropper & Zafonte, 2015).
Ankylosing Spondylitis (AS): It is a rare lifelong condition deemed a form of arthritis that induces stiffness and pain in the spine. It is also called Bechterew disease and originates from the lower back, and consequently, damage joins in other body parts or extends to the neck. It dominantly leads to inflammation between vertebrae and is more severe in men. Though its cause is unclear, it could be due to genetic and environmental factors (MedlinePlus, 2020).
Lumbar Strain/Sprain (LSS): Occurs when muscle fibers are torn or abnormally stretched. The separation of ligaments from their attachment could be due to gradual overuse or sudden injury. In other words, the lumbar spine relies on soft tissues/lower back muscles to support body weight and is readily torn by excessive stress. The most dominant symptom includes sudden lower back pain (Pilitsis, 2020).
Plan
There are five differential diagnoses for the patient in this context. The next step entails tailoring the effective and appropriate treatment to guarantee quick recovery and sustainable living. Suppose there is a need to treat sciatica; it can be intervened with anti-inflammatories such as narcotics, anti-seizure medication, muscle relaxants, and tricyclic antidepressants. Surgery is an option if there are no improvements after 6-8 weeks (Jensen et al., 2019).
References
Aish, M. A., Abu-Jamie, T. N., & Abu-Naser, S. S. (2021). Lower Back Pain Expert System
Using CLIPS. http://dspace.alazhar.edu.ps/xmlui/handle/123456789/2724
American Association of Neurological Surgeons (AANS), (2022). Lumbar Spinal Stenosis.
https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Lumbar-Spinal-Stenosis
Al Qaraghli, M. I., & De Jesus, O. (2021). Lumbar Disc Herniation. In StatPearls
Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560878/
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2014). Seidel’s
Guide to Physical Examination-E-Book. Elsevier Health Sciences.
Jensen, R. K., Kongsted, A., Kjaer, P., & Koes, B. (2019). Diagnosis and treatment of
sciatica. Bmj, 367. doi: https://doi.org/10.1136/bmj.l6273
Pilitsis, J.G, (2020). Low back strain and sprain. American Association of Neurological
Surgeonans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Low-Back-Strain-and-Sprain#:
Ropper, A. H., & Zafonte, R. D. (2015). Sciatica. New England Journal of
Medicine, 372(13), 1240-1248. DOI: 10.1056/NEJMra1410151
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