Assignment: Assessing Musculoskeletal Pain – Advanced Health Assessment

Assignment: Assessing Musculoskeletal Pain – Advanced Health Assessment

Assignment: Assessing Musculoskeletal Pain – Advanced Health Assessment

Assignment: Assessing Musculoskeletal Pain – Advanced Health Assessment

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 each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins of 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 ankles but is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She can 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?

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. What additional history do you need to determine the causes of knee pain? 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?

To prepare:

• With regard to the case study, you were assigned.
• Review this week’s Learning Resources, and consider their insights about the case study.
• Consider what history would be necessary to collect from the patient in your assigned case study.
• 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 appropriate for each case. List five conditions for the patient’s differential diagnosis and justify why you selected each.

Note: For this Discussion, you must complete your initial post before you can view and respond to your colleagues’ postings. Begin by clicking the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click Submit, you cannot delete or edit your posts or post anonymously. Please check your post carefully before clicking on Submit!

Read a selection of your colleagues’ responses.

By Day 6

Respond to one of your colleague’s post 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.

Instructions and formatting

1. This is a 2-3 paragraph essay responds
2. The colleague’s post to responds to is below
3. This responds should cite 2 resources and referenced on a reference page.
4. Writer can cite from one of the resources below. Writer can use own 1 or 2 scholarly articles as well
5. Write paragraphs in APA Format
6. Writer should use basic vocabulary

Resources

Required Readings

URL for the Book and chapters listed above

https://mbsdirect.vitalsource.com/#/user/signin

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.). St. Louis, MO: Elsevier Mosby.

• Chapter 4, “Vital Signs and Pain Assessment” (Previously read in Week 6)
• Chapter 22, “Musculoskeletal System”
• This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system.

Assignment: Assessing Musculoskeletal Pain – Advanced Health Assessment

Episodic/Focused SOAP Note Template

Patient Information:

RD, 15 yo, M, Caucasian

S.

CC: Pain in both knees x 2 weeks

HPI: Patient is a 15 year old Caucasian male complaining of bilateral knee pain. He states the pain has been going on for 2 weeks and started 3 weeks into school basketball practice. He describes the pain as dull and achy with a “catching” sensation under the patella during movement. He states the pain gets worse with movement and gets better when sitting or lying down and after taking NSAIDS. He rates the pain 7/10 at this time. He denies falling, denies blunt trauma to the knees, denies twisting injury.

Current Medications: Ibuprofen 800 mg every 8 hours as needed for knee pain, last dose this morning. Tiger Balm topical to both knees, last application last night.

Allergies: No known drug allergies. No environmental allergies. No food allergies.

PMHx: Childhood immunizations up to date. Flu shot received on 10/3/19. Tonsillectomy, age 6. Ulnar fracture, age 10. No other medical problems.

Soc Hx: Patient is in the 10^th grade at the local high school. He is on the school basketball and track teams. He participates in weight-lifting class. He denies tobacco, alcohol, and illicit drug use. He lives with his mother and father and younger sister.

Fam Hx: Mother: living, age 48, no medical history. Father, living, age 45, history of hypertension, hyperlipidemia. Sister: living, age 12, no medical history. Maternal grandmother: living, age 71, history of hypertension, gout. Maternal grandfather: living, age 75, history of GERD, arthritis, and hypertension. Paternal grandmother: deceased, age 56 of breast cancer. Paternal grandfather: living, age 70, history of hypertension, hyperlipidemia, MI.

ROS:

GENERAL:  Patient denies fevers, denies weight loss

CARDIOVASCULAR:  Denies palpitations, denies lower extremity edema

RESPIRATORY:  Denies shortness of breath or dyspnea

NEUROLOGICAL:  Denies numbness or tingling in lower extremities

MUSCULOSKELETAL:  Denies pain, swelling, or stiffness in back, hips, or ankles. Denies pain in any other joints besides both knees. Denies limp or difficulty walking.

NEUROLOGICAL: Denies weakness in upper or lower extremities.

O.

Physical exam:

VITAL SIGNS: BP 112/68, HR 66, RR 16, SPO2 100% on room air, Temp 97.9 F. Height 5’9”, Weight 148 lbs.

GENERAL: Patient ambulated unassisted to exam table, no alterations in gait noted. Patient sitting up on exam table, alert and oriented, follows commands and converses appropriately. Appropriate height, weight, and cognitive level for developmental age. Lean, muscular build. Mood is friendly. Patient’s mother is at bedside with permission from patient.

CARDIOVASCULAR: Regular rate and rhythm, no murmur, rub, or gallop. 2+ peripheral pulses in upper and lower extremities to include popliteal, dorsalis pedis, and posterior tibial pulses.

RESPIRATORY: Breath sounds are clear and equal bilaterally, equal chest rise and fall, effort is normal and non-labored

MUSCULOSKLETAL: Upper extremities symmetrical, good ROM noted in joints. Hips are symmetrical, knees are symmetrical. No bruising or deformities noted to knees on inspection. No heat, swelling or tenderness noted to popliteal spaces, patellas are midline bilaterally with no swelling or tenderness noted laterally or medially and appropriate concavities noted on extension. Patient does complain of tenderness on palpation to anterior patella and distal to the patella bilaterally. Knee flexion of 130 degrees bilaterally, patient reports mild discomfort on flexion. Knee extension of 10 degrees noted bilaterally, patient reports moderate pain on extension with worse pain on the right. Ballottement test negative for effusion. Bulge sign negative for effusion. McMurray test negative, no grinding or clicking noted, patient denies pain. Anterior and posterior drawer test negative, movement less than 5mm bilaterally. Lachman test negative. Varus and valgus stress test negative for excessive medial or lateral movement of the knee noted. Q angle 15 degrees in right knee, 12 degrees in left knee

NEUROLOGICAL: Grade 5 muscle strength noted on flexion and extension in upper and lower extremities. Sensory motor intact in all extremities.

Diagnostic results:

Ballottement test, bulge sign, McMurray test, drawer test, Lachman test, varus and valgus stress test, Q angle

Bilateral knee x-rays

A.

1. Patellar tendonitis- Dains, Baumann, and Scheibel (2019) indicate that patellar tendonitis is common in athletes that do excessive running and jumping (p. 268). The authors also state that patient will report dull and achy pain and sometimes complain of clicking or popping in the effected joint (p. 268). With this patient’s history of basketball practice and track participation and reported catching sensation, a patellar tendonitis diagnosis is likely. The patient also reports tenderness to the patellar tendon and has a Q angle greater than 10 degrees in both knees.
2. Osgood- Schlatter disease- This condition is common in adolescent males and presents with tenderness, swelling, and warmth to the tibial tuberosity (Dains, Baumann, & Scheibel, 2019, p. 268). The authors cite that this is usually caused by extensive use of the quadriceps muscle, which would be appropriate for this patient considering his history of weight-lifting class. However, his physical assessment revealed no swelling, tenderness, or warmth to the tibial tuberosity.
3. Medial collateral ligament sprain- This type of injury can be caused by blunt trauma to the knee, which this patient denies. These patients can also have signs of joint effusion (Dains, Baumann, & Scheibel, 2019, p. 272). The varus and valgus stress tests check for excessive medial and lateral movement of the knee which could indicate injury to the medical collateral ligament (Ball, Dains, Flynn, Solomon, & Stewart, 2019, p. 528). This patient’s physical exam did not indicate medial collateral ligament instability.
4. Baker’s cyst- Baker’s cysts cause knee pain and stiffness and are characterized by noticeable swelling behind the knee where the cyst is located (Mayo Clinic, 2018, Symptoms section). This patient has knee pain but had no swelling or tenderness to the popliteal spaces.
5. Medial meniscus tear- This type of injury is usually caused by a twisting injury and results in pain and difficulty walking along with a catching sensation during movement (Ball, Dains, Flynn, Solomon, & Stewart, 2019, p. 572). While this patient reports occasionally experiencing this catching sensation, his McMurray test was negative and he reports no difficulty walking or bearing weight. An MRI would be indicated to rule out this diagnosis.

Assignment: Assessing Musculoskeletal Pain – Advanced Health Assessment

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.). St. Louis, MO: Elsevier Mosby.

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.

Mayo Clinic. (2018). Baker’s cyst. Retrieved from https://www.mayoclinic.org/diseases-conditions/bakers-cyst/symptoms-causes/syc-20369950

Instructions and formatting

Respond to one of your colleague’s post 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.

1. This is a 2-3 paragraph essay responds
2. The colleague’s post to responds to is below
3. This responds should cite 2 resources and referenced on a reference page.
4. Writer can cite from one of the resources below. Writer can use own 1 or 2 scholarly articles as well
5. Write paragraphs in APA Format
6. Writer should use basic vocabulary

 Resources

URL for the Book and chapters listed below

https://mbsdirect.vitalsource.com/#/user/signin

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.). St. Louis, MO: Elsevier Mosby.

 

• Chapter 4, “Vital Signs and Pain Assessment” (Previously read in Week 6)
• Chapter 22, “Musculoskeletal System”
• This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system.

 

Patient Initials: XX Age: 46

SUBJECTIVE DATA:

Chief Complaint (CC): Pain in both Ankles

Gender: Female

History of Present Illness (HPI): This is a 46-year-old female who reports to the clinic with complaints of pain in both of her ankles, particularly the right ankle. She was playing soccer over the weekend and heard a “pop.” She can bear weight on it, but it is uncomfortable.

Medications: None mentioned

Allergies: NKDA

Past Medical History (PMH): She reports no history of previous surgeries, blood transfusions, hospitalizations, injuries, or disabilities.

Past Surgical History (PSH): None

Social History: Reports no history of tobacco, alcohol, or drug use.

Immunization History: Immunizations are up to date and takes the Influenza vaccine every year

Significant Family History: She reports no family history from her parents or her siblings. Lifestyle: She plays soccer, no other hobbies or occupation mentioned.

Review of Systems:

General: The patient reports having 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 can bear weight, but it is uncomfortable.

HEENT: No changes in vision or hearing; she does not wear glasses, no mention of
a history of glaucoma, diplopia, excessive tearing, or photophobia. No mention of any issues with a sense of smell. She has had no difficulty chewing or swallowing. She does an annual dental and vision exam.

 

Neck: No pain, injury, or history of disc disease or compression. Breasts: Denies any changes in breasts.

Respiratory: Denies any shortness of breath or difficulty breathing at night, no coughing, or sputum.

CV: No report of chest discomfort, palpitations, or a history of a heart murmur.

GI: Negative for any GI bleeds nausea, and vomiting, or abdominal pain. Denies any problems with bowel movements.

GU: no changes in urinary pattern, no dysuria, incontinence, or blood in urine mentioned.

MS: pain in both ankles, particularly the right one. No back pain or joint aches or stiffness anywhere else.

Psych: No history of anxiety or depression. No sleep disturbances, delusions, or mental health history. She denies suicidal/homicidal history.

Neuro: No syncope episodes or dizziness, no headaches. No change in memory or thinking patterns; denies any falls or seizure history.

Integument/Heme/Lymph: No rashes, itching, or bruising on the skin.

Endocrine: No reports of diabetes, thyroid problems, or issues with growth. No reports of sweating, cold or heat intolerance.

Allergic/Immunologic: Denies any allergies

Assignment: Assessing Musculoskeletal Pain – Advanced Health Assessment

OBJECTIVE DATA:
Physical Exam

Vital signs: None gave, blood pressure, heart rate, respiration, oxygen saturation, height, and weight would be checked.

General: Alert and oriented to person, place, time and surrounding
HEENT: Thorax symmetrical, clear breath sounds in all four quadrants; no rhonchi or wet,

productive cough noted during the exam
Neck: No tenderness or enlargement of lymph nodes

Cardiovascular: Heart rate regular with good S1, S2.

Abdomen: soft and round, normal bowel sounds auscultated x4 quadrants

Musculoskeletal: full range of motion without difficulties in upper extremities. Pain in bilateral lower extremities would also test for dorsiflexion, inversion, flexion of ankles, and toes. Palpate the Achilles tendon, count number of toes, and inspect all toes.

Neurological: Alert and oriented x4

Skin: Warm, moist, denies any open cuts wounds on the body.

Diagnostics:
X-ray, Sonography, Magnetic resonance imaging (MRI)

After getting a full history and background information from the patient, an x-ray should be done to rule out fractures. A plain x-ray of the foot should be taken if the patient mentions bone pain, and the anterior-posterior view should be taken to evaluate the abnormalities. The Ottawa Ankle rule was developed to avoid unnecessary x-rays. It determines if an x-ray should be done if there is any pain in specific regions mentioned or bone tenderness (Polzer, Kanz, Prail, Haasters, Ockert, Mutschier & Grots, 2012). It is appropriate in this scenario as the patient is not pregnant, under 18, or has any head injuries mentioned (Ball, Dains, Flynn, Solomon & Stewart, 2015).

Sonography is valuable for examining the tendons of the ankle joint for ruptures or displacement. MRI’s are also used to diagnose fractures of the lateral ligaments of the ankle (Polzer, Kanz, Prail, Haasters, Ockert, Mutschier & Grots, 2012).

ASSESSMENT:

Dierential Diagnosis: 1.

Ankle sprain

Ankle sprains are the most common pathology accountable for over 67% of soccer-related ankle injuries. The majority of them are sustained during player contact, but sometimes this occurs from direct contact forced on the medial aspect of the lower leg before a strike can cause a player to land with the ankle. Surgical intervention is indicated in severe injuries, but not always. In this scenario, the patient plays soccer and most likely has sustained an ankle sprain (Walls, Rose, Fraser, Hodgkins, Smyth, Egan & Kennedy, 2016).

2. Muscle Strain

This can happen from excessive stretching or forceful contraction. It is often associated with improper exercise warm-up, previous injury, or fatigue. The patient plays soccer. It can be possible that she sustained a strain from warming up before playing soccer (Ball, Dains, Flynn, Solomon & Stewart, 2015).

3. Fracture

This is a partial or complete break of the bone. This usually occurs from trauma like twisting or crushing and is common in athletes or people who play sports. The patient played soccer and complained of ankle pain after playing soccer (Ball, Dains, Flynn, Solomon & Stewart, 2015).

4. Tendinitis

This is the inflammation of the tendon. It is widespread as it is a degeneration of the tendon’s collagen in response to chronic overuse, especially when there is a repetitive strain or injury tendinitis occurs (Bass, 2012). Although it is not mentioned if the patient has had repetitive injuries, it is a possibility when you play a contact sport.

5. Contusion

This is the crushing of the muscle fibers and connective tissues without breaking the skin. It usually occurs during contact sports that involve high speed and objects like balls. It presents with pain, swelling, and sometimes a hematoma. Most soccer, baseball, football, and rugby players sustain these types of injuries (UnityPoint Health, 2015).

Assignment: Assessing Musculoskeletal Pain – Advanced Health Assessment

References

• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis,

MO: Elsevier Mosby.

• Bass, E. (2012). Tendinopathy: Why the Difference Between Tendinitis and Tendinosis Matters. International Journal of Therapeutic Massage & Bodywork, 5(1), 14-17. Polzer, H., Kanz, K. G., Prall, W. C., Haasters, F., Ockert, B., Mutschler, W., & Grote, S. (2012). Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthopedic Reviews, 4(1), e5. http://doi.org/10.4081/or.2012.e5
• UnityPoint Health. (2015, April 20). The Pain of Sports: Foot & Ankle Injuries. Retrieved from https://www.unitypoint.org/livewell/article.aspx?id=d5102982-938f- 43e3-a0db-5cb38fb91164
• Walls, R. J., Ross, K. A., Fraser, E. J., Hodgkins, C. W., Smyth, N. A., Egan, C. J., … Kennedy, J. G. (2016). Football injuries of the ankle: A review of injury mechanisms, diagnosis, and management. World Journal of Orthopedics, 7(1), 8–19. http://doi.org/10.5312/wjo.v7.i1.8