NURS 6512 ASSESSING MUSCULOSKELETAL PAIN

Sample Answer for NURS 6512 ASSESSING MUSCULOSKELETAL PAIN Included After Question

NURS 6512 ASSESSING MUSCULOSKELETAL PAIN

ASSESSING MUSCULOSKELETAL PAIN

The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provides the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams. 

In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting. 

RESOURCES 

NURS 6512 ASSESSING MUSCULOSKELETAL PAIN
NURS 6512 ASSESSING MUSCULOSKELETAL PAIN

 

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.  

WEEKLY RESOURCES 

To prepare: 

  • By Day 1 of this week, you will be assigned to one of the following specific case studies for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor. 
  • Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case. 
  • Review the following case studies: 

Case 1: Back Pain 

A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform? 

 

A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottawa ankle rules to determine if you need additional testing? 

Case 3: Knee Pain 

 

A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform? 

With regard to the case study you were assigned: 

  • Review this week’s Learning Resources, and consider the insights they provide about the case study. 
  • Consider what history would be necessary to collect from the patient in the case study you were assigned. 
  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis? 
  • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. 

Note: When you submit your initial post, please include a header as the first line indicating your assigned case study. For example, “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned. 

BY DAY 3 OF WEEK 8 

Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.  

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply!    

Read a selection of your colleagues’ responses. 

BY DAY 6 OF WEEK 8 

Respond to at least two of your colleagues on 2different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning. 

A Sample Answer For the Assignment: NURS 6512 ASSESSING MUSCULOSKELETAL PAIN

Title: NURS 6512 ASSESSING MUSCULOSKELETAL PAIN

Kendra Hintz 

Jan 16, 2023Jan 16 at 4:47pm 

Manage Discussion Entry 

Discussion – Week 8 with Review of Case Study 3 

Episodic/Focused SOAP Note Template 

 

Patient Information: 

PH, 15-years-old, Male, Filipino 

CC: Knee pain 

HPI: PH, 15-year-old Filipino male presents with bilateral knee pain for over a week. PH describes the pain as dull with occasional “clicking” or “catching” in one or both knees. PH reports that the pain started a couple weeks after basketball season started this year. PH stated he had pain similar to this last spring during track when he started competing in long jump. PH reports that it hurts more after practice than it does after a game stating, “coach has me doing extra running and jumping drills, he’s really hard on us.” 

Location: Knees, under patella 

Onset: A week ago 

Character: dull 

Associated signs and symptoms: occasional clicking of one/both knees, “catching” sensation 

Timing: “after practice” 

Exacerbating/relieving factors: track and basketball practice make it worse; ibuprofen and ice/heat help make it ache less 

Severity: 6/10 pain scale 

Current Medications: 

Ibuprofen 200mg PO after practice 

Multivitamin (OTC) PO daily 

Allergies: 

Denies food or environmental allergies. 

Adhesives- rash at site 

Tylenol- nausea 

PMHx: 

Current and up to date on all immunizations, influenza vaccine received this season, but did not receive COVID-19 vaccines. 

Tonsillectomy and adenoidectomy- 2012 

Fractured Ulna- 2020 from basketball injury 

Reports several sprained ankles from basketball and track. 

Denies concussions or previous knee injuries.

Soc Hx: 

Freshman in high school, track and field athlete (long jumper), and JV basketball player (small forward). Lives with parents and younger brother. Denies tobacco, alcohol, or illicit drug use. Denies sexual activity, advises he has a girlfriend. PH reports always wearing a seatbelt. PH plays golf with friends outside of school and enjoys playing Xbox on weekends with his friends from the track team. PH reports he has several friends that support him at school and family that encourage him in academics and sports. PH advises he feels a lot of pressure from basketball coach to “be the best”. 

Fam Hx: 

Mother: HTN, Hyperlipidemia, Depression 

Father: DM2, HTN, Hyperlipidemia 

Brother: No known history. 

MGM: HTN 

MGF: No information available 

PGM: HTN, Hyperlipidemia 

PGF: Deceased at 54 from MI 

ROS: 

Example of Complete ROS: 

GENERAL:  No weight loss, fever, or chills. Reports general weakness after practices and games. Reports academic and athletic success. 

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears: No hearing loss or tinnitus. Nose: No sneezing, congestion, loss of smell, runny nose, or epistaxis. Throat: No sore throat, erythema, or lesions. 

SKIN:  No rash or itching. Reports having occasional acne on forehead. Reports underarm hair. 

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema. 

RESPIRATORY:  No shortness of breath, cough, or sputum. Reports infrequent, unproductive cough after running sprints during basketball practice. 

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. Last BM 1/16/23 no melena, constipation, or loose stool. 

GENITOURINARY:  Denies burning or pain with urination, frequency, or nocturia.   

NEUROLOGICAL:  No dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. Reports headaches after studying all night for tests. 

MUSCULOSKELETAL:  Reports dull bilateral knee pain. Ankle pain previously with sprain—currently resolved. Denies immobility. 

HEMATOLOGIC:  No anemia or bleeding. Identifies bruise on right shin from exercise injury. 

LYMPHATICS:  No enlarged nodes. No history of splenectomy. 

PSYCHIATRIC:  No history of depression or anxiety. Reports feeling pressure from basketball coach to “be the best.” Reports a supportive social and family group. 

ENDOCRINOLOGIC:  No reports of cold or heat intolerance. No polyuria or polydipsia. Reports sweating more than last year and must apply deodorant again before practice. 

ALLERGIES:  No history of asthma, environmental or food allergies. Acetaminophen- nausea. Adhesives (tape)- rash at site. 

Physical exam: 

VS: BP 115/64, HR 80, RR 16, O2 98%, 36.8 C, 65 inches, 54.4kg, BMI 20 

GENERAL: PH is dressed appropriately and well groomed. PH able to maintain erect sitting position for examination and appropriate historian for current chief complaint, requires assistance from mother on allergies and past medical history. 

NEUROLOGICAL: Alert and oriented. Cranial nerves intact. Upper and Lower extremity strength equal bilaterally. Reflexes 2+. 

SKIN: Acne present near hairline of forehead. No scaring, lesions, rashes, or moles present. Appropriate for ethnicity. Hair pattern presenting at underarms. Nails are short without brittle texture, pitting, or ridging. 

HEENT: Head- symmetric. Ears: symmetric bilateral, negative tenderness and discharge, eardrum pearly grey, and no erythema. Eye: PERRLA 3/2 brisk equal response, negative nystagmus, white sclera, brown iris, and eye lids equal. 20/20 vision using Snellen chart. Nose: nares equal, no erythema in nasal cavity, no postnasal drip, patent turbinates, no polyps, PH can identify smells presented. 

NECK: No palpable/enlarged lymph nodes. Trachea midline. Appropriate ROM bilateral. 

RESPIRATORY: No SOB. Breath sounds clear a/p in all lobes. No adventitious breath sounds. Chest expansion symmetric with inhalation and exhalation. Work of breath appropriate for examination, no dyspnea noted. 

CARDIOVASCULAR: S1, S2 heard, rate and rhythm regular. No carotid, renal, or aortic bruits identified. Extremities color appropriate for ethnicity and warm. Radial and dorsalis pedis pulses 2+. 

ABDOMEN: Symmetric, normoactive bowel sounds all quadrants, no palpable masses, no tenderness or guarding. 

GENITALIA: Minimal pubic hair noted, uncircumcised, no tenderness at penis or scrotum, no masses identified. 

MUSCULOSKELETAL: ROM of all extremities appropriate, stiffness and guarding of knees occurs when transitioning from sitting to standing. Clicking noise noted when patient stood. No joint swelling or redness. No kyphosis, lordosis, or scoliosis. Grade 5 muscle strength. Obvious discomfort noted with initial transition from sitting to standing and stepping up on step. Q angle 14°. 

Diagnostic results: 

Ultrasound- This a non-invasive test that can provide dynamic structure images of the knee to confirm or eliminate possible diagnoses (Santana & Sherman, 2020). 

MRI- Can be used to identify patellar tendon abnormalities as well as osseous and soft tissue injuries (Nacey et al., 2017). Ultrasounds used in conjunction with MRI’s can both eliminate diagnoses, but also confirm. 

Erythrocyte Sedimentation Rate (ESR)- this lab test measures the sedimentation rate of red blood cells to detect inflammation. This can be used to diagnose juvenile arthritis (JA) (Daines et al., 2019). 

CBC- this lab test would be used to identify an increase in WBC which can identify inflammation as well but is not diagnostic (Dains et al., 2019). 

X-ray- a four view radiograph image (a/p, lateral, and skyline views are useful to eliminate JA as well as determine if there are osseous abnormalities (Santana & Sherman, 2020). 

 

  1. A.

Differential Diagnoses 

  1. Patellar Tendinitis – According to Santana & Sherman (2020), patellar tendinitis (also 

known as “jumper’s knee”) is a result of overuse and stress on the patellar tendon and quadriceps. History and signs of patellar tendinitis include overuse of the jumping or running motion and symptoms include dull pain at the patella and clicking can accompany the pain (Dains et al., 2019). Due to PH recent overuse of patellar tendons and quadriceps with long jumping in the spring and currently overworked during basketball season has caused the patient to present with dull knee pain and clicking and catching of knees making patellar tendinitis most likely. Ruling out other diseases by utilizing US, MRI, X-ray, CBC, and ESR since there is no definitive test to confirm patellar tendinitis (Santana & Sherman, 2020). 

  1. Chondromalacia of the Patella – Dains et al. (2019) is caused by trauma to the patella, misalignment, or anatomical abnormalities. Four-view radiography should be used to rule out JA. Chondromalacia pain occurs with activity rather a result of activity making it less likely to be the diagnosis since PH pain occurs after strenuous activity and there is no pain on patella palpitation. Habusta & Griffin (2020) also state that this is more prominent is young female adolescents, not males. 
  1. Juvenile Arthritis – Dains et al. (2019) describe history of JA as joint stiffness and pain, fatigue, weight loss, and refusal to walk with symptoms being limited ROM, bilateral joint pain, rash, fever, and joint swelling. PH presents with painful knees bilaterally, but does not present with fever, joint swelling, or rash. A CBC would demonstrate increased WBC, ESR would be positive for antinuclear antibodies and rheumatoid factor. Most JA diagnosis occurs before 16-years-old, it does not appear this patient is likely to have JA, but should not be eliminated until diagnostic tests and labs can be completes. 
  1. Bursitis – Bursitis is caused by chronic overuse resulting in local tenderness and swelling, limited joint movement, and muscle weakness (Dains et al., 2019). US and MRI testing combined can be used to identify bursitis and the depth and severity of inflammation (Williams & Sternard, 2019). PH’s injury is acute and is not from chronic overuse; however should not be eliminated until an US and MRI can rule out bursitis. This is not a primary diagnosis due to lack of symptoms mirroring what the patient is presenting with. 
  1. Patellar Maltracking – “Patellar maltracking occurs as a result of an imbalance in the dynamic relationship between the patella and trochlea. This is often secondary to an underlying structural abnormality,” (Jibri et al., 2019). Imaging used to diagnose maltracking includes MRI to note subtle changes in dislocation of the patella; however, without any documented history of dislocation it makes it difficult to diagnose. 
  1.  

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. 

 

            When assessing a patient getting a full history is essential to assist in diagnosing a patient or ordering the most appropriate tests and imaging to rule out possible diagnoses. This patient case study only described the pain and stated his age, current activities were up to us to fill in which guides the differential diagnosis. If this patient did not demonstrate overuse of the patella, it would make some differential diagnoses unlikely. Based on the information provided and filled in determines the overall diagnostic tests and diagnosis. Listed in the subjective and objective data is both information provided and information needed to create possible differential diagnoses. 

 

 

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. 

Habusta, S. F., & Griffin, E. E. (2020). Chondromalacia Patella. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459195/Links to an external site. 

Jibri, Z., Jamieson, P., Rakhra, K. S., Sampaio, M. L., & Dervin, G. (2019). Patellar maltracking: an update on the diagnosis and treatment strategies. Insights into imaging, 10(1), 65. https://doi.org/10.1186/s13244-019-0755-1 

Nacey, N. C., Geeslin, M. G., Miller, G. W., & Pierce, J. L. (2017). Magnetic resonance imaging of the knee: An overview and update of conventional and state of the art imaging. Journal of magnetic resonance imaging : JMRI, 45(5), 1257–1275. https://doi.org/10.1002/jmri.25620 

Santana, J. A., & Sherman, A. l. (2020). Jumpers Knee. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532969/ 

‌ Williams, C. H., & Sternard, B. T. (2019). Bursitis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513340/