Sample Answer for NURS 6512 ASSESSING MUSCULOSKELETAL PAIN Included After Question
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
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 2 different 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
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).
- A.
Differential Diagnoses
- 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).
- 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.
- 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.
- 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.
- 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.
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/
A Sample Answer 2 For the Assignment: NURS 6512 ASSESSING MUSCULOSKELETAL PAIN
Title: NURS 6512 ASSESSING MUSCULOSKELETAL PAIN
Patient Information:
Initials, Age, Sex, Race: a 46-year-old female patient.
S.
CC (chief complaint): ‘My ankles are painful.’
HPI: The patient is a 46-year-old female that came to the department with complaints of pain in both ankles. She reports being more concerned with the right ankle. The patient notes that she was playing soccer over the weekend when she heard a ‘pop.’ She can bear weight but is uncomfortable. The patient rates her pain as 7/10, with increased intensity with weight. The patient denied any radiating pain. Rest and ibuprofen relieve the pain. She also uses cold compressions to sooth the pain.
Current Medications: The patient currently uses ibuprofen 500 mg as needed for pain.
Allergies: The patient has latex allergy. She denied any allergic reaction to drugs and environmental allergens.
PMHx: The patient’s immunization history is up-to-date. Her last tetanus immunization was 12/10/2022. She has a history of hospitalization due to pneumonia. She has no history of surgery or blood transfusion.
Soc Hx: The patient is a teacher. She is married with two children. She resides in an owned property with her family. She engages in sports activities weekly. She does not smoke or takes alcohol. She does not have any history of drug and substance use. She reports wearing a helmet and seat belts when riding and driving. Her support system includes family, friends, and church members. She is a devoted Christian.
Fam Hx: Her diseased mother died of hypertension. She was also diabetic and diagnosed at some point with anxiety disorder. Her living father has colon cancer. Her sister was diagnosed with asthma a year ago. Her paternal grandfather died of heart disease.
ROS:
GENERAL: The patient is dressed appropriately for the occasion. She is alert and oriented to self-, others, time, and place. She denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: The patient denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: The patient denies hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: The patient denies rash or itching.
CARDIOVASCULAR: The patient denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: The patient denies shortness of breath, cough or sputum.
GASTROINTESTINAL: The patient denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: The patient denies burning on urination, urgency and frequency. She is menopausal.
NEUROLOGICAL: The patient denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. She also denies change in bowel or bladder control.
MUSCULOSKELETAL: The patient reports bilateral ankle joints. The right ankle hurts the most. She reports some tenderness on the anterior aspect in the right ankle. She is weight bearing but uncomfortable.
HEMATOLOGIC: The patient denies anemia, bleeding or bruising.
LYMPHATICS: The patient denies enlarged nodes. There is no history of splenectomy.
PSYCHIATRIC: The patient denies history of depression or anxiety.
ENDOCRINOLOGIC: The patient denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: The patient reports latex allergy. She denies food, drug, or environmental allergic reaction.
O.
Physical exam:
Vitals: Temperature: 37.6, BP 122/80, P-100, RR 22 bpm, SPO2 98%
General: The patient is well-groomed for the occasion. She is alert and oriented. She is responsive to questions and maintains normal eye contact. There is no evidence of any distress, fatigue, or weight loss.
Chest/Lungs: The chest rises symmetrically with respirations. The patient does not demonstrate nasal flaring or discharge. The nares are patent. On auscultation there are wheezes, rales, crackles, or rhonchi. The lungs are clear in all the lobes.
Heart/Peripheral Vascular: The patient does not have central or peripheral cyanosis. S1 and S2 heart sounds heard. There are no murmurs or S3 heart sounds. The peripheral pulses are adequate with capillary refill of less than 3 seconds. The extremities are warm to touch with no ulcers.
Musculoskeletal: The patient reports bilateral ankle pain. On assessment there is limited range of motion with plantar flexion, inversion and dorsiflexion. The right ankle appears edematous to the anterior aspect. There is skin discoloration over the right ankle. There is no cyanosis or tissue ischemia or bruising. There are no deformities. The patient is weight bearing with some discomfort. On palpation, the skin is warm to touch. The lateral malleolus area is tender to touch. The anterior talofibular ligament is inflamed.
Lymphatics: There is no lymphadenopathy or weight gain or loss.
Psychiatric: The patient denies any history of mental health disorders.
Diagnostic results:
One of the diagnostic investigations needed to develop an accurate diagnosis for the client is x-ray. An x-ray of the right ankle would be important to visualize the ligaments, joint, and bones. The results will determine if the problem is due to soft tissue injury, fracture, or ligament tear. The other recommended diagnostic is magnetic resonance imaging. MRI will provide detailed cross-sectional images of soft tissue involvement. A CT scan of the ankle joint may also be needed to guide in the diagnosis (Chen et al., 2019). Ultrasound may be needed to determine the functioning of the tendon or ligaments in different foot movements.
A.
Differential Diagnoses
Ankle sprain is the primary diagnosis for the patient. An ankle sprain develops when a joint is suddenly subjected to a move that strains the ligaments and tendons. It is most common in individuals that engage in activities such as sports. Patients that suffer ankle sprains often complain of symptoms that align with those seen in the patient in this case study. They include pain on weight bearing, swelling, tenderness, bruising, reduced range of motion, and popping sound during the injury (Chen et al., 2019; Delahunt & Remus, 2019).
Ankle fracture is the secondary diagnosis that should be considered for this patient. An ankle fracture develops when a bone is broken from fall, twit, or trauma. The fractures vary based on the severity of the cause. Patients that suffer ankle fractures experience symptoms that include deformity, tenderness, swelling, throbbing pain, bruising, and difficulty walking (Scheer et al., 2020). The patient in the case study is least likely to be suffering from fractured ankle since there are no evident deformities in the ankles.
The other diagnosis to be considered for the patient is tendon rupture. A rupture of the Achilles tendon may occur in cases of extreme stress and pressure to the ankle joint and tendon. The affected patients often experience symptoms such as thickened Achilles tendon, pain near the heel, pain that worsens with activity, and difficulties in flexing the affected leg. The additional symptoms include a pop sound during the time of injury and patient being unable to stand on the toes of the affected extremity (Svensson et al., 2019; Tarantino et al., 2020). Additional diagnostics will help in differentiating between ankle sprain and ruptured Achilles tendon.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Chen, E. T., McInnis, K. C., & Borg-Stein, J. (2019). Ankle Sprains: Evaluation, Rehabilitation, and Prevention. Current Sports Medicine Reports, 18(6), 217. https://doi.org/10.1249/JSR.0000000000000603
Delahunt, E., & Remus, A. (2019). Risk Factors for Lateral Ankle Sprains and Chronic Ankle Instability. Journal of Athletic Training, 54(6), 611–616. https://doi.org/10.4085/1062-6050-44-18
Scheer, R. C., Newman, J. M., Zhou, J. J., Oommen, A. J., Naziri, Q., Shah, N. V., Pascal, S. C., Penny, G. S., McKean, J. M., Tsai, J., & Uribe, J. A. (2020). Ankle Fracture Epidemiology in the United States: Patient-Related Trends and Mechanisms of Injury. The Journal of Foot and Ankle Surgery, 59(3), 479–483. https://doi.org/10.1053/j.jfas.2019.09.016
Svensson, R. B., Couppé, C., Agergaard, A.-S., Ohrhammar Josefsen, C., Jensen, M. H., Barfod, K. W., Nybing, J. D., Hansen, P., Krogsgaard, M., & Magnusson, S. P. (2019). Persistent functional loss following ruptured Achilles tendon is associated with reduced gastrocnemius muscle fascicle length, elongated gastrocnemius and soleus tendon, and reduced muscle cross-sectional area. TRANSLATIONAL SPORTS MEDICINE, 2(6), 316–324. https://doi.org/10.1002/tsm2.103
Tarantino, D., Palermi, S., Sirico, F., & Corrado, B. (2020). Achilles Tendon Rupture: Mechanisms of Injury, Principles of Rehabilitation and Return to Play. Journal of Functional Morphology and Kinesiology, 5(4), Article 4. https://doi.org/10.3390/jfmk5040095