NURS 6512 Week 8 Discussion: Assessing Muscoskeletal Pain

The body is constantly sending signals about its health. One
of the most easily recognized signals is pain. Musculoskeletal conditions
comprise one of the leading causes of severe long-term pain in patients. The
musculoskeletal system is an elaborate system of interconnected levers that
provide 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.

Note: By Day 1 of this week, your Instructor will have
assigned you to one of the following specific case studies for this Discussion.
Also, 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.

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?

spine

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 Ottowa ankle rules to determine if you need
additional testing?

ankle

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?

knee

To prepare:

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

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 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

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.

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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

1. 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. 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).
3. 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).
4. 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.
5. Lumbar muscle strain- present with pain in the lower back which is relieved by lying flat.

 

NURS 6512 Week 8 Discussion: Assessing Muscoskeletal Pain 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