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?
Case 2: Ankle Pain
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:
M.S., 15 years, male, African American.
S.
CC (chief complaint): “Dull pain in both knees.”
HPI: M.S. is a 15-year-old African American patient with complaints of dull pain in both his knees. He reports that the knees click and experience a catching sensation below the patella. The pain began three months ago. He claims the pain worsens during activity. He uses ibuprofen with no adequate relief. The patient rates the knee pain 6/10.
Current Medications: Over-the-counter ibuprofen for pain treatment (not effective).
Allergies: Penicillin (itching and rash). No environmental and food allergies.
PMHx: Childhood Immunization up-to-date (Polio, MMR, Hep B, and DTaP/T4. The flu vaccine was taken last year. No hx of significant diseases and surgery.
Soc Hx: M.S. is the only child raised by his two parents. He is a middle school student who plays basketball. He engages in school basketball competitions. He denies the use of alcohol, tobacco, or illicit drugs. He sleeps approximately 8 hours per night.
Fam Hx: Paternal grandfather died at 75 due to COPD-related complications. Maternal grandmother is alive and has diabetes and asthma. Mother has asthma and hypertension.
ROS:
- GENERAL: No fever, shivering, chills, fatigue, or unintended weight changes.
- HEENT: Eyes: Declines blurred vision, yellow sclerae, eye pain, or loss of vision. Ears, Nose, Throat: No hearing alterations, ear pain, nasal congestion, nasal drip, sneezing, or scratchy throat.
- SKIN: No itching, rash, or hives.
- CARDIOVASCULAR: No chest tightness, pain, or discomfort. Denies tachycardia or edema.
- RESPIRATORY: Denies cough, breath shortness, or phlegm production.
- GASTROINTESTINAL: No nausea, anorexia, constipation, diarrhea, abdominal pain, vomiting, or bleeding.
- GENITOURINARY: Denies delayed or painful urination. No urine odor or color changes.
- NEUROLOGICAL: No dizziness, ataxia, headaches, or tingling/numbness. No problems in bladder and bowel control
- MUSCULOSKELETAL: Reports dull pain in knees and catching sensation below the patella. No fractures or back pain.
- LYMPHATICS: No swollen nodes or hx of splenectomy
- ENDOCRINOLOGIC: No polydipsia, polyuria, excessive sweating, or hypersensitivity to cold/heat.
O.
Physical exam:
V.S: T-98.5 F, P-72, R-16, BP-114/78, Ht- 4’5” Wt- 11 lbs
General: Patient attentive. No signs of distress.
Head: Atraumatic and normocephalic head.
EENT: Dry and pink oral mucosa.
NECK, No masses or cervical lymphadenopathy.
Lungs: No crackles, rhonchi, wheezing. Lungs clear.
Cardiovascular: RRR, or S1S2. No edema in the extremities.
Musculoskeletal: No joint swelling. Range of motion in knees limited.
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Diagnostic results:
Complete blood count: WBC 10,500 mcL
Comprehensive metabolic panel: the test measures the body’s levels of electrolytes that may interfere with the patient’s metabolism and body functioning.
X-ray: The imaging tests create images of internal tissues, and it would be helpful in visualizing the patient’s knees (McCance & Huether, 2018).
Differential Diagnosis
Patellofemoral pain syndrome: This condition causes dull pain around the patella. The catching sensation below the patella is
also attributed to this disorder. The patient’s participation in sports increases the risk of patellofemoral pain syndrome (Vora et al., 2017).
Osgood-Schlatter disease: Adolescents who engage in sports may develop Osgood-Schlatter disease, which may cause knee pain because of inflammation of the patellar tendons. However, Osgood-Schlatter disease causes a painful lump which is the absence in this client (Watanabe et al., 2018).
Trauma to knee: Trauma may cause pain and clicking of the knees. Teenagers engaging in sports have a high risk of trauma to the knee (Sweeney et al., 2020). However, the subjective findings in this patient do not provide evidence of trauma.
References
McCance, K. L., & Huether, S. E. (2018). Pathophysiology: the biologic basis for disease in adults and children. Elsevier Health Sciences.
Sweeney, E., Rodenberg, R., & MacDonald, J. (2020). Overuse Knee Pain in the Pediatric and Adolescent Athlete. Current Sports Medicine Reports, 19(11), 479-485. https://doi.org/10.1249/JSR.0000000000000773
Vora, M., Curry, E., Chipman, A., Matzkin, E., & Li, X. (2017). Patellofemoral pain syndrome in female athletes: a review of diagnoses, etiology and treatment options. Orthopedic Reviews, 9(4). https://dx.doi.org/10.4081%2For.2017.7281
Watanabe, H., Fujii, M., Yoshimoto, M., Abe, H., Toda, N., Higashiyama, R., & Takahira, N. (2018). Pathogenic factors associated with Osgood-Schlatter disease in adolescent male soccer players: a prospective cohort study. Orthopaedic Journal of Sports Medicine, 6(8), 2325967118792192. https://doi.org/10.1177%2F2325967118792
A Sample Answer 2 For the Assignment: NURS 6512 Assessing Musculoskeletal Pain
Title: NURS 6512 Assessing Musculoskeletal Pain
SUBJECTIVE DATA:
Chief Complaint (CC): “Pain in my lower back for the past one month”
History of Present Illness (HPI): S.K is a 42-year-old Caucasian male patient who reported to the clinic with pain in his lower back that had lasted for about a month. he reports that the pain radiates to his left leg sometimes. The patient reports that the pain is worse when working, and is less disturbing when resting. He has been taking ibuprofen which he claims to provide minimal relief.
Location: lower back
Onset: about a month ago
Character: constant and sharp pain radiating to the left leg
Associated signs and symptoms: None
Timing: When handling strenuous work
Exacerbating/ relieving factors: Any movement worsens the pain. Resting and Ibuprofen provides minimal relief.
Severity: 7/10 on a pain scale
Medications:
- Ibuprofen 800mg PO PRN for the back pain
Allergies:
No known environmental, food, or drug allergies.
Past Medical History (PMH):
Denies any history of a serious medical diagnosis
Past Surgical History (PSH):
Denies ever undergoing any surgical procedure in the past.
Sexual/Reproductive History:
Heterosexual
Personal/Social History:
Married with 3 children
Works in a book store downtown.
Has never smoked tobacco or marijuana.
Confirms taking 2 to 3 beers occasionally when with friends.
Immunization History:
Flu shot 17/2/2022
Covid Vaccine #1 2/1/2021 #2 3/1/2021 Moderna
All other immunization up to date
Significant Family History:
Mother- with HTN and DM
Father- with gout and kidney disease
Maternal grandmother- with kidney disease
Maternal grandfather- died from a stroke
Paternal grandmother- with COPD
Paternal grandfather with CAD, HTN, and COPD.
He has 2 daughters and one son who are all healthy with no significant health complications.
Lifestyle:
The patient works in a bookstore downtown. He is happily married to a junior school teacher with 3 children. They live on the outskirts of the city in a 3 bedroom apartment in a safe neighborhood. The means of transport is good, with easily accessible fresh water and healthcare services. He tried as much as possible to eat a healthy diet together with his family. He walks the dog every evening for about a kilometer as a form of exercise. Uses seat belts when in the car, with safety equipment such as a first-aid kit available in their home. He is a strong church member and socializes with his friends mostly over the weekend.
Review of Systems:
General: No recent changes in body weight. Complains of pain in his lower back. Denies constipation, fatigue, chills, fever, or generalized body weakness.
HEENT: Head: No signs of trauma or headache reported. Eyes: Denies blurred vision, use of corrective lenses, excessive tearing, or redness. Ears: No tinnitus, itchiness, or hearing loss. Nose: no congestion, running nose, sinus problems, or nose bleeding. Throat & Mouth: No sore throat, coughing, swallowing difficulties, or dental problems. Neck: No tenderness, signs of injury, enlarged tonsils, or a history of disc disease or compression.
Respiratory: No wheezing, coughing, shortness of breath, or breathing difficulties.
CV: Denies chest pain, edema, PND, orthopnea, syncope, or palpitations. Dyspnea on exertion
GI: No abdominal tenderness, constipation, diarrhea, distention, changes in bowel movement, or jaundice.
GU: Denies incontinence, urinary frequency, hematuria, dysuria, or burning sensation when urinating.
MS: Reports lower back pain which sometimes radiates to the left leg. He rates the pain at 7/10 on a pain scale. The severity of the pain however worsens when walking or turning when sleeping. The patient confirms that the pain has lasted for about a month, making it harder to exhibit a full range of movement on the left leg. No numbness, swelling, or redness was reported.
Psych: Denies paranoia, hallucinations, delirium, suicidal ideation, mental disturbance, memory loss, anxiety or depression, or a history of psychosis.
Neuro: Reports back pain that radiates to the left leg. Denies vertigo, tremors, syncope, seizures, paresthesia, or transient paralysis.
Integument/Heme/Lymph: No bruising, ecchymosed, ulcers, lesions, or rashes. No signs of enlarged lymph nodes.
Endocrine: Denies heat intolerance, cold intolerance, polyuria, polyphagia, or polydipsia.
Allergic/Immunologic: Denies hay fever, urticaria, persistent infections, or HIV exposure.
A Sample Answer 4 For the Assignment: NURS 6512 Assessing Musculoskeletal Pain
Title: NURS 6512 Assessing Musculoskeletal Pain
OBJECTIVE DATA
Physical Exam:
Vital signs: B/P 140/96, left arm, sitting, regular cuff; P 88 and regular; T 98.9 Orally; RR 18; non-labored; Wt: 215 lbs; Ht: 5’8; BMI 32.69
General: The patient appears healthy, and well oriented in person, place, and time. Seems to be uncomfortable and in moderate pain.
HEENT: External ears normal, with no deformities or lesions. External nose normal with no deformities or lesions. Bilaterally clear canals. Intact tympanic membrane with good movement and no fluid. Grossly intact bilateral hearing. Normal nasal mucosa, septum and turbinates. Complete and good hygienic dentation.
Neck: Supple with no masses. Trachea midline, No thyroid nodules, tenderness, or masses.
Chest/Lungs: Bilaterally clear to auscultation. Tactile fremitus normal. No signs of egophony. Normal respiratory effort displayed with no use of accessory muscles.
Heart/Peripheral Vascular: S1, and S2, note. Normal cardiac rhythm with no murmur, gallop, or rubs.
ABD: Suprapubic surgical scar, obese, non-tender, soft, and non-distended abdomen with no masses.
Genital/Rectal: The patient did not consent to this examination.
Musculoskeletal: Low back pain noted, radiating to the left lower leg. No evidence of trauma affecting the area was noted. Tenderness increases with extension, flexion, and twisting. Limited ROM in the left leg.
Neuro: Cranial nerves: II – XII grossly intact; 2+, symmetric, reflexes.
Diagnostics/Lab Tests and Results:
CBC – To evaluate for spinal infections
CSF analysis- For suspected spinal infection or inflammatory etiologies
X-ray of the spine- for flexion-extension views to identify spondylolisthesis and spinal instability.
MRI of the spine- to assess for suspected myelopathy or radiculopathy.
Electromyography (EMG)- to confirm compressions caused by spinal stenosis or herniated disks (Urits et al., 2019).
Assessment:
Differential Diagnosis (DDx):
- Sciatica: This condition is characterized by pain that normally radiates along the sciatic nerve path, which branches from the patient’s lower back through to the buttocks and hip, and down to each leg (Kim et al., 2018). However, sciatica normally affects one side of the body. The patient in the provided case study presents with lower back pain that radiates to the left leg, which is a great indication of sciatica as the primary diagnosis.
- Lumbar disc herniation: LDH is characterized by lower back pain and is common among adults between the age of 35 and 50 years. It normally results from changes in the structure of the lower lumbar spinal disk between the 4th and 5th vertebrae and between the 5th lumbar vertebra and the 1st sacral vertebra (Benzakour et al, 2019). Most patients normally present with symptoms such as lower back pain, radicular pain, limited trunk flexion, and weakness at the lumbosacral nerve roots distribution. The patient in the provided case study displayed lower back pain, however, an MRI of the spinal column is needed to confirm this diagnosis.
- Lumbar spinal stenosis: LSS is associated with narrowing of the spinal canal located in the lower back resulting in pain. Stenosis causes pressure on the patient’s spinal cord or nerves connecting the spinal column and the muscles (Deer et al., 2019). As such patients will present with lower back pain just like the one in the provided case study. However physical examination is required to assess for the presence of loss of sensation, abnormal reflexes, and weakness to confirm this diagnosis.
- Lumbar muscle strain: LMS is described as an injury to the lower back characterized by mild to moderate lower back pain. The injury can lead to damage to the muscle or tendons causing spasms and soreness (Urits et al., 2019). An x-ray is however needed to confirm the impact of the injury on the tendon or muscle to confirm the diagnosis
- Ankylosing spondylitis: This is an inflammatory disorder, that can lead to some of the spinal bones fusing over time. It is characterized by pain in the joints and the back (Ogdie et al., 2019). Symptoms normally appear early in life, including reduced flexion of the spine. The patient only presented with back pain which radiates to the left leg with no joint pain or reduced flexion of the spine.
Primary Diagnoses:
1.) Sciatica
PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]
References
Benzakour, T., Igoumenou, V., Mavrogenis, A. F., & Benzakour, A. (2019). Current concepts for lumbar disc herniation. International orthopedics, 43(4), 841-851. https://doi.org/10.1007/s00264-018-4247-6
Deer, T. R., Grider, J. S., Pope, J. E., Falowski, S., Lamer, T. J., Calodney, A., … & Mekhail, N. (2019). The MIST guidelines: the Lumbar Spinal Stenosis Consensus Group guidelines for minimally invasive spine treatment. Pain Practice, 19(3), 250-274. https://doi.org/10.1111/papr.12744
Kim, J. H., van Rijn, R. M., van Tulder, M. W., Koes, B. W., de Boer, M. R., Ginai, A. Z., … & Verhagen, A. P. (2018). Diagnostic accuracy of diagnostic imaging for lumbar disc herniation in adults with low back pain or sciatica is unknown; a systematic review. Chiropractic & manual therapies, 26(1), 1-14. https://doi.org/10.1186/s12998-018-0207-x
Ogdie, A., Benjamin Nowell, W., Reynolds, R., Gavigan, K., Venkatachalam, S., de la Cruz, M., … & Park, Y. (2019). Real-world patient experience on the path to diagnosis of ankylosing spondylitis. Rheumatology and Therapy, 6(2), 255-267. https://doi.org/10.1007/s40744-019-0153-7
Urits, I., Burshtein, A., Sharma, M., Testa, L., Gold, P. A., Orhurhu, V., … & Kaye, A. D. (2019). Low back pain, a comprehensive review: pathophysiology, diagnosis, and treatment. Current pain and headache reports, 23(3), 1-10. https://doi.org/10.1007/s11916-019-0757-1