Discussion: Assessing Musculoskeletal Pain
Patient Information:
Initials: C.A, Age: 46 years, Sex: Female, Race: African American
S.
CC (chief complaint): Bilateral ankle pain
HPI: C. A is a 46 is African American aged 46 years old. She presents with complaints of pain in her bilateral ankle, especially on the right side. She claims to have heard a “pop” while playing soccer over the weekend. She can tolerate weight, but it is painful. Her major worry is her right ankle.
Location: Bilateral ankle
Onset: Abrupt
Character: Sharp but not radiating pain
Associated signs and symptoms: Ankle enlargement and inadequate right ankle movement.
Timing: The pain has lasted for two days. It is irregular with each episode taking about 15-20 minutes.
Exacerbating/ relieving factors: Pain is intensified by walking, tolerating weight, or sitting. Pain is momentarily eased by cold compresses.
Severity: Pain is worse on the right ankle at about 5/10 compared to the left ankle which is about 2/10.
Current Medications: None
Allergies: No identified drug and food allergies
Past Medical History: No history of chronic medical conditions, blood transfusion, or previous surgeries. Flu vaccine: December 2020
Social History: She is a professional teacher and the team’s soccer captain. She likes playing soccer on weekends. She does not take alcohol, smoke tobacco, or use illicit drugs.
Family History: Her parents are all alive. Her mother is diabetic but effectively managed by metformin. She is not living with her husband because they separated two years ago. She has a 20-year-old college-going daughter.
ROS:
GENERAL: No fever, chills, night sweats, or changes in weight
HEENT: Eyes: Refutes loss of vision, blurred vision, or yellow sclera. Ears, Nose, and Throat: Refutes ear discharges, hearing loss, dysphagia, nasal congestion, or sore throat.
SKIN: Reports no rash, itching, or skin discoloration.
CARDIOVASCULAR: No paroxysmal nocturnal dyspnea, palpitation, chest pain, or orthopnea.
RESPIRATORY: No cough, shortness of breath, sputum, or difficulty in breathing. GASTROINTESTINAL: No alteration in changes in abdominal distention, or bowel routines.
GENITOURINARY: Refutes hematuria, frequency, or dysuria. The last menstrual period was on 07/09 /2022.
NEUROLOGICAL: Denies convulsion, headache, syncope, or alterations in the functions of bowel and bladder.
HEMATOLOGIC: No anemia, bruising, or bleeding.
LYMPHATICS: No record of splenectomy. No lymphadenopathy.
PSYCHIATRIC: Refutes anxiety, depression, hallucinations, or delusions.
ENDOCRINOLOGIC: No cold, polydipsia, polyuria, and heat intolerance.
ALLERGIES: No history of asthma, eczema, or hives.
O.
Physical exam
Vital Signs: P 78 RR 19 Temp 98.4 F, BP 123/74 mmHg, Weight 128 lbs., Height 5′ 5″
General: A middle-aged female adult of African American origin. She has a minor discomfort. She is oriented and alert.
Respiratory: Vesicular breath sounds in entire lung zones, a symmetric chest that budges with respiration. No crackles or wheezing.
Cardiovascular: No murmurs. PMI in the fifth intercostal space, normoactive precordium, midclavicular line. S1 and S2 detected. Ecchymosis measuring 2 cm by 2 cm was noted around the lateral malleolus. Tenderness of the lateral malleolus was observed, particularly above the anterior talofibular ligament. Restricted range of motion of the right ankle, especially on plantar flexion, inversion, and dorsiflexion. Bilateral skin intact. No noted erythema or edema on the left ankle. The usual range of motion was noted on the left ankle. Noted bilateral constructive dorsalis pedis. Bilateral intact sensation, No noted deformity, crepitus, or bony tenderness.
Neurological: GCS 15/15, oriented to person, place, and time. Cranial nerves are intact, sensation in every dermatome is intact, and typical bulk, typical tone, and reflexes in all joints. Regular functions of bladder and bowel.
Diagnostic results:
The prone anterior drawer test: This test evaluates the reliability of the ankle’s lateral ligamentous complex. The test is crucial for the patient’s case.
Talar tilt test: This test focuses on the calcaneofibular ligament. The patient suffered pain around the ligament area.
Eversion test: This test is conducted to assess the reliability of the deltoid ligament. It is negative in the patient’s case.
Imaging: Based on the Ottawa Ankle rules, conducting a series of X-rays is crucial is necessary where the pain is noted in the malleolar area alongside any of the following signs; tenderness above the posterior periphery of the distal 6 cm or medial malleolus’ tip, tenderness above the posterior periphery of the distal 6 cm or lateral malleolus’ tip, and incapacity to tolerate weight shortly following an injury (Murphy et al., 2020). The patient, C.A, met the Ottawa rules. As a result, a right lateral X-ray was conducted, which indicated swelling in the soft tissue. There is a need for an MRI of the ankle or more perspectives to effectively describe the ligaments involved.
A.
Differential Diagnoses
Lateral Ankle Sprain: This pain is a frequent injury associated with sports. It occurs majorly with the ankle inversion and entails the lateral ligamentous complex, which comprises the calcaneofibular and posterior talofibular ligament, and anterior talofibular ligament that are damaged in reducing order (Martin et al., 2021). Patients with this condition often have a hematoma, tenderness above the sprained ligament, inadequate range of motion, and soft tissue swelling. These characteristics are common with the patient in this case. The “pop” sound she reported is an indication of a clear ligament tear. As such, lateral ankle sprain is the primary diagnosis in this patient.
Ankle Fracture: This condition characterizes one or more ankle joint bones including the tibia, talus, and fibular. It presents as a cute immediate pain, tenderness, incapacity to tolerate weight, limited movement, pain, skin abnormalities, and swelling (McKeown et al., 2020). It is not the major diagnosis since ankle fractures are normally high-energy injuries but the patient can tolerate the weight.
Syndesmotic Ankle Injury: This condition is also called a high ankle sprain. It characterizes an injury to a minimum of one of the ligaments that encompass the distal tibiofibular syndesmosis (Raheman et al., 2022). It is also attributed to injuries associated with sports with an abrupt twisting force. It leads to more proximal pain above the ankle.
Anterior Impingement: This condition connotes strapped structures down the tibiotalar joint’s anterior margin in terminal dorsiflexion (Chen et al., 2019). It often characterizes ankle pain and restricted movement. It is also linked to considerable abnormalities in the osseous and soft tissues.
Achilles Tendinitis: This condition characterizes Achilles tendon inflammation. It manifests with swelling, pain, and erythema at the point of tendon placement into the calcaneus. It also manifested in incapability to move and tightness (Lee & Lee, 2018). In the case at hand, the patient reported pain and tenderness in the ankle’s lateral area. However, in Achilles tendinitis, the pain should manifest in the posterior area of the ankle.
This section is needless in this course. However, it will be necessary for future courses.
References
Chen, L., Wang, X., Huang, J., Zhang, C., Wang, C., Geng, X., & Ma, X. (2019). Outcome comparison between functional ankle instability cases with and without anterior ankle impingement: a retrospective cohort study. The Journal of Foot and Ankle Surgery, 58(1), 52-56. https://doi.org/10.1053/j.jfas.2018.07.015
Lee, Y. K., & Lee, M. (2018). Treatment of infected Achilles tendinitis and overlying soft tissue defect using an anterolateral thigh free flap in an elderly patient: A case report. Medicine, 97(35). Doi: 10.1097/MD.0000000000011995
Martin, R. L., Davenport, T. E., Fraser, J. J., Sawdon-Bea, J., Carcia, C. R., Carroll, L. A., … & Carreira, D. (2021). Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 51(4), CPG1-CPG80. https://www.jospt.org/doi/10.2519/jospt.2021.0302
McKeown, R., Kearney, R. S., Liew, Z. H., & Ellard, D. R. (2020). Patient experiences of an ankle fracture and the most important factors in their recovery: a qualitative interview study. BMJ open, 10(2), e033539. http://dx.doi.org/10.1136/bmjopen-2019-033539
Murphy, J., Weiner, D. A., Kotler, J., McCormick, B., Johnson, D., Wisbeck, J., & Milzman, D. (2020). Utility of Ottawa ankle rules in an aging population: evidence for addition of an age criterion. The Journal of Foot and Ankle Surgery, 59(2), 286-290. https://doi.org/10.1053/j.jfas.2019.04.017
Raheman, F. J., Rojoa, D. M., Hallet, C., Yaghmour, K. M., Jeyaparam, S., Ahluwalia, R. S., & Mangwani, J. (2022). Can weightbearing cone-beam CT reliably differentiate between stable and unstable syndesmotic ankle injuries? A systematic review and meta-analysis. Clinical Orthopaedics and Related Research®, 10-1097. Doi: 10.1097/CORR.0000000000002171
Sample Answer for NURS 6512 Discussion: 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.
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
Photo Credit: University of Virginia. (n.d.). Lumbar Spine Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/5lumbar/01anatomy.html. Used with permission of University of Virginia.
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
Photo Credit: University of Virginia. (n.d.). Lateral view of ankle showing Boehler’s angle [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/8ankle/01anatomy.html. Used with permission of University of Virginia.
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
Photo Credit: University of Virginia. (n.d.). Normal Knee Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/7knee/01anatomy.html. Used with permission of University of Virginia.
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: Before you submit your initial post, replace the subject line (“Discussion – Week 8”) with “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 “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
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 Discussion: Assessing Musculoskeletal PainTitle: NURS 6512 Discussion: Assessing Musculoskeletal PainS. Medications: Tylenol 1000mg as needed for pain, Advil 800mg as needed for pain, 40mg PMH: Positive history of GERD FH: Mother has a hx of stomach cancer, but is still living; Father has HTN. No history of premature cardiovascular disease in first degree relatives. SH : Smokes 1 pack of cigarettes daily x 10 years, drinks 1-3 beers on the weekends while watching the game; divorced for the last 5 years – Allergies: NKDA including medications, food, and environmental Immunizations: UTD on immunizations ROS Musculoskeletal-Negative for joint pain, swelling, or notable bone deformity. Denies weakness O. VS: BP 142/96; P 89; R 22; T 97.2; 02 95% Wt 205lbs; Ht 72” General–Pt appears uncomfortable, no s/s of diaphoresis, fever, or pallor Cardiovascular—Negative for JVD, carotid bruit. S1 et S2 noted per auscultation, RRR. Negative for murmurs Gastrointestinal–The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; negative for bruits. No masses or splenomegaly are noted. Negative for pain or tenderness Pulmonary— Lungs are clear to auscultation and percussion bilaterally Musculoskeletal-Negative for joint pain, swelling, or heat. ROM intact. Negative for muscle weakness. Positive for pain when moving left lower extremity and bending over. C/o low back pain that sometimes radiates to his left leg. Diagnostic results: Weight bearing radiographs of the lumbar spine, complete blood count, erythrocyte sedimentation rate, c-reactive protein |
A.
Differential Diagnosis:
- Sciatica-
- Sciatica pain often starts in the lower back and radiates down the posterior and lateral aspects of the leg (Dains et al., 2019). In addition, sciatica is due to nerve root compression (Ball et al., 2023). These repetitive activities have been identified as an occupational and lifestyle hazard for our patient.
- Lumbar Disk Herniation-
- Lumbar disk herniation can cause low back and leg pain (Benzakour et al., 2019). Pain associated with a lumbar disk herniation is often described as tingling, prickling, or burning (Hasvik et al., 2022)
- Spinal Stenosis
- Spinal Stenosis presents with pain in the lower back and thigh (Katz et al., 2022). Pain may continue to progress to the lower leg and foot. The patient may eventually experience difficulty with ambulation, but this doesn’t necessarily occur immediately.
- Arachnoiditis
- Arachnoiditis can present as burning low back pain that travels down the leg (Maillard et al., 2023)
- Spondylolysis
- Spondylolysis can cause lumbar back pain that is typically relieved with rest (Li et al., 2022). The disease may progress to nerve compression.
Primary Diagnosis/Presumptive Diagnosis: Sciatica
Involved Nerve Roots and Testing
- Sensation is the first tool involved in testing nerves roots that protrude from the lumbar spine. This can be done using a sharp object lightly applied to random areas and ask the patient to differentiate between sharp and dull.
- The Patellar Reflex evaluates nerves between L2 and L4. is tested by striking the tendon directly below the patella.
- The Achilles Reflex is utilized to evaluate the nerves between L5 to S2. With the knee flexed and the hip externally rotated, hold the foot in dorsiflexion and strike the Achilles tendon.
- The Plantar Reflex evaluates nerves between L4 and S2. The end of the reflex hammer is drawn lightly up the lateral side of the sole of the foot and across the ball of the foot.
Symptoms to Explore
Additional symptoms that should be explored include loss of control of bowels or bladder, and numbness on the medial aspects of the thighs. In addition, motor strength in the back and lower extremities should be evaluated.
Maneuvers to Perform
Two assessment maneuvers would be very important to do for this client. The first is the Patrick’s Test (Urits et al, 2019). This consists of having the patient lie supine while the leg is passively flexed, abducted, and externally rotated. If the client experiences pain in the groin, this is indicative of hip pathology. If pain is experienced in the low back, this indicates pathology with the sacroiliac joint.
Secondly, the Straight Leg Test should be performed to determine nerve root involvement (Urits et al., 2019). This test is performed while the patient lies supine. The patient’s leg is lifted at the heel with the keep straight. The hip is flexed to a 70-90 degree angle. If the radicular pain is reproduced, the test is positive.
Support for Diagnostic Tests
Since the patient is presenting with symptoms for longer than 4 weeks, we can start by getting weight bearing radiographs of the lumbar spine (Urits et al., 2019). If pain persists despite minimally invasive treatments, further imaging such as an MRI, may be necessary. Laboratory tests including a complete blood count, erythrocyte sedimentation rate, and c-reactive protein should be performed to ensure the patient does not have any kind of bacterial infection at the site (See et al., 2021)
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.
Benzakour, T., Igoumenou, V., Mavrogenis, A. F., & Benzakour, A. (2019). Current concepts for lumbar disc herniation. International Orthopaedics, 43(4), 841–851. https://doi.org/10.1007/s00264-018-4247-6
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.
Hasvik, E., Haugen, A. J., & Grøvle, L. (2022). Symptom descriptors and patterns in lumbar radicular pain caused by disc herniation: a 1-year longitudinal cohort study. BMJ Open, 12(12), e065500. https://doi.org/10.1136/bmjopen-2022-065500
Katz, J. N., Zimmerman, Z. E., Mass, H., & Makhni, M. C. (2022). Diagnosis and Management of Lumbar Spinal Stenosis: A Review. JAMA, 327(17), 1688–1699. https://doi.org/10.1001/jama.2022.5921
Li, N., Amarasinghe, S., Boudreaux, K., Fakhre, W., Sherman, W., & Kaye, A. D. (n.d.). Spondylolysis. Orthopedic Reviews, 14(3), 37470. https://doi.org/10.52965/001c.37470
Maillard, J., Batista, S., Medeiros, F., Farid, G., Paulo Santa Maria, Perret, C., Koester, S. W., & Bertani, R. (2023). Spinal Adhesive Arachnoiditis: A Literature Review. https://doi.org/10.7759/cureus.33697
See, Q., Tan, B., & Kumar, D. (2021). Acute low back pain: diagnosis and management. Singapore Medical Journal, 62(6), 271–275. https://doi.org/10.11622/smedj.202108
Urits, I., Burshtein, A., Sharma, M., Testa, L., Gold, P. A., Orhurhu, V., Viswanath, O., Jones, M. R., Sidransky, M. A., Spektor, B., & Kaye, A. D. (2019). Low back pain, a comprehensive review: Pathophysiology, diagnosis, and treatment. Current Pain and Headache Reports, 23(3). https://doi.org/10.1007/s11916-019-0757-1
A Sample Answer 2 For the Assignment: NURS 6512 Discussion: Assessing Musculoskeletal Pain
Title: NURS 6512 Discussion: 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.
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
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.
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
Photo Credit: University of Virginia. (n.d.). Lumbar Spine Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/5lumbar/01anatomy.html. Used with permission of University of Virginia.
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?
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Case 2: Ankle Pain
Photo Credit: University of Virginia. (n.d.). Lateral view of ankle showing Boehler’s angle [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/8ankle/01anatomy.html. Used with permission of University of Virginia.
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
Photo Credit: University of Virginia. (n.d.). Normal Knee Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/7knee/01anatomy.html. Used with permission of University of Virginia.
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: Before you submit your initial post, replace the subject line (“Discussion – Week 8”) with “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 “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
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 3 For the Assignment: NURS 6512 Discussion: Assessing Musculoskeletal Pain
Title: NURS 6512 Discussion: Assessing Musculoskeletal Pain
S.
CC: “Ankle Pain”
HPI: The patient is a 46-year-old woman experiencing pain in both ankles, although the right one feels more severe. The agony started over the weekend when she was playing soccer and heard a sound in her ankles, which might have been because of joint dislocation during the game. The ankle pain is due to the rapture of the Achilles tendon at the back of the leg. The aching is around the ankle region and it is accompanied by discomfort, despite her manageable weight. The patient has tried using analgesics to relieve the pain.
Medication: Analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) to relieve pain (Foster et al., 2018).
PMH: Manageable weight and positive for avulsion fracture and joint inflammation.
FH: The patient is married to a 55-year-old African American man, whose mother died from arthritis. No history of cardiovascular diseases. The patient lacks a family history of stroke, respiratory disorders, and cardiac illnesses.
SH: Negative for substance use, does not consume alcohol, previously engaged in different physical activities, and has been married for eighteen years.
Allergies: Cold environment, proteins, and animal furs, such as cats’ and dogs’.
Immunization: A double dose of the COVID-19 vaccine.
ROS
General: The patient records mild chills, headache, and fever. No breathing difficulties. Mild joint pain and general body discomfort.
Respiratory: The breathing pathways are clear, no shortness of breath, and no inflammation in the lungs.
Blood cell count: The patient has a healthy blood count, strong red blood cells, and an efficient supply of oxygen to the brain and other body tissues.
Arthritis: The patient has joint pains, mild friction at the ankle, redness of the ankle bone, ruptured Achilles tendon, swollen muscles, and damaged and deformed joints.
Diabetic ulcers: No diabetic wound, the patient reports mild venous, and arterial ulcers.
Obesity: The patient reports a manageable weight, enjoys healthy sleeping patterns, no sleep apnea, and no reported varicose veins and gallstones.
O.
VS: BP 185/104; P 95; R 24; T 97.0; 02 95% Wt 230lbs; Ht 69
General: The patient is in mild pain, uncomfortable, and strains to walk due to agony.
Respiration: The patient breathes eighteen times per minute
Heartbeat is normal
No recorded chest pains
No dyspnea, tachypnea, hypopnea, and hyperpnea
Blood cell count: The hemoglobin count is 15.2 g/dL, white blood cells are 4.7 billion cells per liter, and platelets are 214 billion per liter.
Arthritis: The patient records sufficient synovial fluids, inflammation of the ankle bone, and ruptured Achilles tendon.
Diabetic wound: No cuts on the dermis.
Obesity: Weight is 230lbs and height is 69
Differential diagnoses:
Chest pain: Ruptured tendons lead to the damaging of veins and arteries, resulting in excessive pain (Liu et al., 2020). The rationale for chest pain assessment is to identify damage to the tendons and blood vessels, which leads to excessive agony.
Abdominal pain: The musculoskeletal system consists of the entire bones, and damage to the abdomen can affect the limbs, leading to ankle pain (Dains et al., 2018)
Mobility assessment: Patients with affected legs experience pain in the limb, back, and lower abdomen. Assessment of mobility is important to identify the affected musculoskeletal region impacting the limbs (Ball et al., 2019).
Back pain: The back hosts the spinal cord that anchors the skeletal system. Examining the causes of back pain helps note the damage to the spine, which may affect other anchoring organs (Sullivan, 2019).
Arthritis: Friction in the joints causes pain (Hicks et al., 2020). Testing for arthritis helps identify the underlying causes of joint and ankle ache in the limbs.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2018). Advanced health assessment and clinical diagnosis in primary care (5th ed.). Elsevier Mosby.
Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., Ferreira, P. H., Fritz, J. M., Koes, B. W., Peul, W., Turner, J. A., Maher, C. G., Buchbinder, R., Hartvigsen, J., Cherkin, D., Foster, N. E., Maher, C. G., Underwood, M., van Tulder, M., . . . Woolf, A. (2018). Prevention and treatment of low back pain: Evidence, challenges, and promising directions. The Lancet, 391(10137), 2368–2383. https://doi.org/10.1016/s0140-6736(18)30489-6
Hicks, C., Levinger, P., Menant, J. C., Lord, S. R., Sachdev, P. S., Brodaty, H., & Sturnieks, D. L. (2020). Reduced strength, poor balance and concern about falls mediate the relationship between knee pain and fall risk in older people. BMC Geriatrics, 20(94). https://doi.org/10.1186/s12877-020-1487-2
Liu, H., Zhang, J., Yu, J., Li, D., Jia, Y., Cheng, Y., Zhang, Q., Liao, X., Liu, Y., Wu, J., Zeng, Z., Cao, Y., Zeng, R., Wan, Z., & Gao, Y. (2020). Prognostic value of serum albumin-to-creatinine ratio in patients with acute myocardial infarction: Results from the retrospective evaluation of acute chest pain study. Medicine, 99(35). https://dx.doi.org/10.1097%2FMD.0000000000022049
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). F. A. Davis.
A Sample Answer 4 For the Assignment: NURS 6512 Discussion: Assessing Musculoskeletal Pain
Title: NURS 6512 Discussion: Assessing Musculoskeletal Pain
S.
CC: Low back pain for one month
HPI: The patient is a 42-year-old Caucasian man who has been experiencing lower back pain since struggling to lift a large object at work a month ago. The pain is described as “sharp and scorching” and radiates down his leg’s left side. Sleep deprivation and difficulty working are among the symptoms described by the patient. With exercise, bending over, and straining, the pain worsens. The level of discomfort is an eight on a ten-point scale. Rest and ibuprofen 600mg orally every four hours to relieve pain, which is assessed at a four out of 10 for intensity.
Location: low back
Onset: one month ago
Character: the pain is sharp and scorching and radiates down his leg’s left side.
Associated signs and symptoms: sleep deprivation
Timing: after straining, bending, or exercise
Exacerbating/ relieving factors: exacerbated with bending or straining, relieved by taking pain medication.
Severity: 4/10 pain scale
Current Medications: ibuprofen 200mg prn pain, Losartan 50mg orally daily, and rosuvastatin 20mg orally daily.
Allergies: No Known Food or Drug Allergies, allergic to latex or pollen.
PMH: The patient denies having ever had arthritis or osteoporosis in her past. The patient has a history of hypertension and hyperlipidemia that is controlled with medication, seasonal allergies, and cholecystectomy on August 17th, 2018. Pt denies having undergone any other procedures or hospitalization. Tdap (06/12/2021) and flu and pneumonia vaccines (10/07/2021) are all current on the patient’s medical record.
Soc Hx: the patient enjoys spending time with friends and playing slow-pitch softball. He also used to play baseball while in college. The patient is married with two teenage children who live in a remote region, attend church regularly, and volunteer their time. The patient denies using illicit drugs or cigarettes.
Fam Hx: Father 64 with hypertension and hyperlipidemia; mother 60 with hypothyroidism; wife 34; son 14, healthy; daughter 12, healthy; mother 60 with hypertension and hypothyroidism; father 64; mother 60; wife 34; son 14, healthy; daughter 12, healthy.
ROS:
GENERAL: fatigue, weakness, denies having fever.
HEENT: patient denies changes in vision or blurry vision and denies cough, congestion, or hearing loss.
SKIN: reports no itching or rash
CARDIOVASCULAR: no dizziness, chest pain, or edema.
RESPIRATORY: denies cough, wheezing, or sputum
GASTROINTESTINAL: No nausea, vomiting, or diarrhea
GENITOURINARY: patient denies polyuria, dysuria, frequency, or urgency.
NEUROLOGICAL: patient denies dizziness, headache, syncope, or hx of fainting
MUSCULOSKELETAL: Lower back pain that radiates down the patient’s left leg is creating aberrant gait patterns and restricted range of motion in the patient. The patient denies having ever had arthritis, gout, or a fall.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam
V/S: V/ S: B/P 130/80, P 87, RR 19, T 98.4 F, O2 97%, Wt 202lbs, Ht 71”
GENERAL: The patient is sitting straight on the test table with a small grimace, and some grumbling can be heard. NAD, which is neatly groomed and appropriately attired, gives the impression that he is older than he appears. The patient is attentive and gives thoughtful responses.
HEENT: the mouth has no ulcers, no scars, ears are in the correct orientation.
CHEST: no chest pains, no wheezes, normal breath sounds.
MUSKULOSKELETAL: Muscle tone and strength are excellent, except for the left leg, which is weak due to pain. Pain in the lower back left hip, and a lack of mobility causes the left leg. Scoliosis is not present, and the spine is straight and symmetrical with no masses or nodules palpable and no soreness observed. The back is symmetrical.
Diagnostic results:
x-ray: To eliminate the possibility of a broken bone, a tumor, or bony protrusion, an X-ray is performed (Jenkins et al., 2018). Low Back Pain (Acute) claimed that quick x-ray use was not evidence-based practice, and AHRQ suggests waiting six weeks if pain continues to perform x-rays (Fujimoto et al., 2109).
A.
Differential Diagnoses
- Lumber sciatica- Lower back discomfort should always be considered to be caused by radiculopathy, which is caused by compression of nerve roots and results in back pain that radiates into the lower extremities (Kim et al., 2018).
- 2. Degenerative disc disease- Back discomfort radiates down the leg when fibrocartilage-based structures between the vertebrae begin to degrade or protrude against nerve roots or the spinal cord, which is what causes this problem (Battié, Joshi & Gibbons, 2019).
- Lumbar spinal stenosis- pain that begins in the lower back and buttocks and can travel down the legs can be caused by a narrowing of the spinal cord canal caused by bone or ligament hypertrophy (Lee et al., 2020).
- Spinal fracture- An injury to the vertebrae in the lower back can result in discomfort and the irritation of nerve roots, which can cause pain to radiate via the affected nerves.
- Lumbar muscle strain- present with pain in the lower back which is relieved by lying flat.
References
Battié, M. C., Joshi, A. B., & Gibbons, L. E. (2019). Degenerative disc disease. Spine, 44(21), 1523-1529. https://doi.org/10.1097/brs.0000000000003103
Fujimoto, K., Inage, K., Eguchi, Y., Orita, S., Toyoguchi, T., Yamauchi, K., Suzuki, M., Kubota, G., Sainoh, T., Sato, J., Shiga, Y., Abe, K., Kanamoto, H., Inoue, M., Kinoshita, H., Norimoto, M., Umimura, T., Koda, M., Furuya, T., … Ohtori, S. (2019). Dual-energy X-ray Absorptiometry and Bioelectrical impedance analysis are beneficial tools for measuring the trunk muscle mass of patients with low back pain. Spine Surgery and Related Research, 3(4), 335-341. https://doi.org/10.22603/ssrr.2018-0040
Jenkins, H. J., Downie, A. S., Maher, C. G., Moloney, N. A., Magnussen, J. S., & Hancock, M. J. (2018). Imaging for low back pain: Is clinical use consistent with guidelines? A systematic review and meta-analysis. The Spine Journal, 18(12), 2266-2277. https://doi.org/10.1016/j.spinee.2018.05.004
Kim, J., Van Rijn, R. M., Van Tulder, M. W., Koes, B. W., De Boer, M. R., Ginai, A. Z., Ostelo, R. W., Van der Windt, D. A., & 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). https://doi.org/10.1186/s12998-018-0207-x
Lee, B. H., Moon, S., Suk, K., Kim, H., Yang, J., & Lee, H. (2020). Lumbar spinal stenosis: Pathophysiology and treatment principle: A narrative review. Asian Spine Journal, 14(5), 682-693. https://doi.org/10.31616/asj.2020.0472
Rubric Guidelines
| Performance Category | 10 | 9 | 8 | 4 | 0 |
| Scholarliness
Demonstrates achievement of scholarly inquiry for professional and academic decisions. |
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| Performance Category | 10 | 9 | 8 | 4 | 0 |
| Application of Course Knowledge –
Demonstrate the ability to analyze, synthesize, and/or apply principles and concepts learned in the course lesson and outside readings and relate them to real-life professional situations |
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| Performance Category | 5 | 4 | 3 | 2 | 0 |
| Interactive Dialogue
Replies to each graded thread topic posted by the course instructor, by Wednesday, 11:59 p.m. MT, of each week, and posts a minimum of two times in each graded thread, on separate days. (5 points possible per graded thread) |
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Summarizes what was learned from the lesson, readings, and other student posts for the week. |
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| Grammar, Syntax, APA
Note: if there are only a few errors in these criteria, please note this for the student in as an area for improvement. If the student does not make the needed corrections in upcoming weeks, then points should be deducted. Points deducted for improper grammar, syntax and APA style of writing. The source of information is the APA Manual 6th Edition |
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| Total Participation Requirements
per discussion thread |
The student answers the threaded discussion question or topic on one day and posts a second response on another day. | The student does not meet the minimum requirement of two postings on two different days | |||
| Early Participation Requirement
per discussion thread |
The student must provide a substantive answer to the graded discussion question(s) or topic(s), posted by the course instructor (not a response to a peer), by Wednesday, 11:59 p.m. MT of each week. | The student does not meet the requirement of a substantive response to the stated question or topic by Wednesday at 11:59 pm MT. |