health assessment

Discussion:Assessing Musculoskeletal 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 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

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.

COLLEAGUE 1

CASE STUDY

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?

COLLEAGUE 1 RESPONSE

What nerve roots might be involved?

The spine, muscles, intervertebral discs, and nerves make up the back (National institute of neurological disorders and stroke, 2020). The lumbar vertebrae (L1-L5) sustain the weight of the upper body. The intervertebral discs cushion the bones while the body moves (National Institute of neurological diseases and stroke, 2020). Anterior and posterior ligaments stabilize the vertebrae, while tendons connect the muscles to the spinal column (NIH, 2020). Eleven pairs of nerves connect the spinal cord to the brain, controlling movement and transmitting impulses (National institute of neurological diseases and stroke, 2020). Lumbar and sacral nerve roots are involved in lower back pain (National institute of neurological disorders and stroke, 2020). Sciatica pain radiates along the sciatic nerve’s course from the lower back to the hips, buttocks, and legs. Sciatica only affects one side of the body (Mayo clinic, n.d.).

How would you test for each of them?

Physical exam: To test the patient’s spine, have him walk (Cleveland Clinic, 2020). Ask patient to walk on his toes and heels to test calf strength (Cleveland clinic, 2020).

Straight leg test: While resting on his back, slowly elevate each leg (from 35 to 75 degrees), noting where the pain begins. This test identifies the affected nerves and disks (Cleveland Clinic, 2020). Also, other actions and stretches can assist localize pain and test muscular flexibility and strength (Cleveland clinic, 2020).

What other symptoms need to be explored?

Low back pain that is numb, shock-like, or searing; the pain may spread to the buttocks and down to one of the legs (Mayo clinic, n.d.).

What are your differential diagnoses for acute low back pain?

Sciatica, caused by sciatic nerve compression in the lower back, buttocks, and back of one leg. It occurs when a herniated disk, bone spur or spinal stenosis compresses portion of the sciatic nerve (National institute of neurological disorders and stroke, 2020).

Leg inflammation, discomfort and numbness are caused by compression (Mayo Clinic, n.d.).

Spinal stenosis: Spinal stenosis causes low back pain by compressing the spinal cord and nerves (National institute of neurological diseases and stroke, 2020).

Spondylolisthesis, This occurs when a lower spine vertebra falls out of place, compressing spinal nerves (National Institute of Neurological Disorders and Stroke, 2020).

Osteomyelitis: Infections of the vertebrae, particularly the intervertebral discs (discitis) and the sacroiliac joints (sacroiliitis), cause low back pain (National Institute of neurological disorders and stroke, 2020).

Cauda equina syndrome a ruptured disc pushes into the spinal canal, pressing on the lumbar and sacral nerve roots bundle. Untreated, this disease can cause permanent neurological damage (National Institute of neurological disorders and stroke, 2020).

What physical examination will you perform?

Check the alignment of the back landmarks and notice the spine curves.

Palpate the paravertebral muscles.

Percuss for back pain.

Measure range of motion for forward flexion (75-90 degrees), hyperextension (30 degrees), lateral bending (35 degrees), and upper trunk rotation (30 degrees).

Examine the hips for symmetry, buttock size, and gluteal fold number and level.

Hip range of motion. Hip flexion with extended knee is 90 degrees; flexion with flexed knee is 120 degrees. 30 degrees hip hyperextension with knee extended Hip abduction is 45 degrees, adduction is 30 degrees. Internal rotation should be 40° and outward rotation 45°.

Examine muscular strength with knee flexed and extended, abduction and adduction, and with legs uncrossed (Ball, 2019).

What special maneuvers will you perform?

Specific tests include:

The National Institute of Neurological Disorders and Stroke (2020).

For detecting an infection, fracture, or bone condition. Radioactive material is delivered into the bloodstream and accumulated in the bones, especially in abnormalities. Scanner pictures can detect improper bone metabolism, blood flow, and joint disease (National Institute of neurological diseases and stroke, 2020).

Discography involves injecting a contrast dye into a spinal disc that may be causing low back discomfort. If the disc is the culprit, the fluid pressure will recreate the person’s symptoms. The dye helps CT scans show damaged tissues.

Nerve conduction studies (NCS) use two electrodes to activate a muscle’s nerve and record its electrical impulses to diagnose nerve damage (National institute of neurological disorders and stroke, 2020).

Disc rupture, spinal stenosis, and other soft tissue structures cannot be seen on conventional x-rays (National Institute of Neurological Disorders and Stroke, 2020; Friedman et al., 2010).

Magneto-resonance imaging (MRI) provides a computer-generated image of bone structures and soft tissues like muscles. Uncertainty about the cause of the pain may necessitate an MRI (National Institute of Neurological Disorders and Stroke 2020; Friedman et al. 2010).

Bone fractures, vertebral injuries, spinal spurs, malignancies, and infections can all be seen on X-ray. (National Institute of Neurological Disorders and Stroke, 2020; Cleveland Clinic, 2020; Friedman et al., 2010).

Episodic/Focused SOAP Note Template

Patient Information:

AS, 42, male, Caucasian

S.

CC (chief complaint) “lower back pain”

HPI: patient is a 42-year-old Caucasian male with a complaint of pain in his lower back for the past month. Patient states that the pain sometimes radiates to his left leg.

Location: lower back

Onset: past month

Character: sometimes radiates to his left leg.

Associated signs and symptoms: What aggravates the pain?

Timing: is there specific time that the pain is more

Exacerbating/ relieving factors: What helps or worsen the pain

Severity: 7/10 pain scale

Current Medications: ask for medication including dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products as well as when the last dose was taken.

Allergies: include medication, food, and environmental allergies and a description of the allergy signs and symptoms.

PMHx: include immunization status; include date of last dose of tetanus shut; any major illnesses and surgeries.

Soc Hx: include patient’s job and hobbies, marriage and family status, use of tobacco, alcohol, or illicit drugs both previous and current. Use of seat belts; text/cell phone use while driving, working smoke detectors in the house, safe living environment, and support system.

Fam Hx: past and present illnesses with possible genetic predisposition, contagious or chronic illnesses parents, grandparents, siblings, and children. Include the cause of death of any deceased first degree relatives.

ROS:

GENERAL: Patient denied any recent weight gain, no fever, no chills, and no weakness

HEENT: Eyes: No headache, no abnormal vision changes or yellow sclera. No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN: Denied any skin rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Denied burning on urination or any urinary problem.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: complained of low back pain, joint pain or stiffness.

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety. Denied any suicidal or homicidal thoughts

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:

General: Patient came in alert and oriented x 4 but anxious. Well developed and well groomed. Speech was clear with normal thought process. He was cooperative with assessment and voluntarily gave information.

Walk Test: to see how patient’s spine carries his weight (Cleveland clinic, 2020). Assessing patient walking on his toes and heels helps to check the strength of his calf muscles (Cleveland clinic, 2020).

Straight leg test: Raising each leg slowly while lying on his back with legs straight (from angle 35 to 75 degrees) helps to identify the specific area that pain begins, and the specific nerves and disks affected (Cleveland clinic, 2020). Other stretches and movement may also help to check muscle flexibility and strength (Cleveland clinic, 2020).

Head: EENT: No sign of head injury; no visual or hearing problem; No shortness of breath or distress.

Vital signs will be checked and recorded. Height and weight will be measured and recorded.

Current pain level will be noted.

References:

Discussion:Assessing Musculoskeletal 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 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

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.

COLLEAGUE 2

CASE STUDY

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?

COLLEAGUE 2 RESPONSE

S:

CC: I was playing soccer over the weekend and heard a “pop.” Right Ankle Pain

HPI: A 46-year-old woman who has complained of pain in both ankles but is concerned about the right ankle. Patient is able to bear weight but reports being uncomfortable. Patient has not had any leg or lower extremity pain before today.

PMH: Soft tissue injuries before as a teenager with both ankles sprained, no past surgery, last period 14 day ago

FH: Mother has Diabetes and HTN Age 75, Father passed from Colon Cancer at the age of 65 Y/O

SH: Diet with vegetables and salads mainly with very little protein, exercise daily (jogging), no history of smoking

O: 46 Y/O Woman unable to bear much weight on the right ankle, 5/0 pain in the right ankle

VS: 139/82 HR: 98 T: 98.6 R: 18 Wt: 123 Ht: 5”4

General: Negative for fever chills, Patient grimacing in pain

Cardiovascular: Patient HR elevated

Gastrointestinal: Abdominal sounds hard in all 4 quadrants, Patient has no massess or brusing present

Pulmonary: Patient has no SOB, lungs are CTA

Musco skeletal: Swelling of the right ankle and ecchymosis. Palpate heat, tenderness, swelling or resistance to movement in the right ankle. Palpated for crepitus (break) no crepitus felt. Ottawa ankle rules must be applied and the tenderness 6 cm distal to the posterior edge of the tibia. Patient unable to bear weight comfortability for at least four steps.

A: Differential Diagnosis :

Primary Diagnsosis Ankle Fracture: Bone tenderness along the distal of the posterior edge of the tibia 6 cm. Patient reported playing soccer over the weekend and hear a “pop”. Ankle fractures can be caused by various modes of trauma, e.g., twisting, impact, and crush injuries (Wire et al., 2011). Drawer test performed and instability shown. Pain at the site means a fracture or at least the need to obtain imaging series, Ankle X-Ray.

Stress Fracture: In contrast to acute fractures, which typically occur with a single maximal load, stress fractures occur due to repetitive, submaximal loading of a bone, leading to microfractures that are unable to heal due to bone resorption and bone formation imbalances. On physical examination, pain with weightbearing or range of motion of a joint near a stress fracture may be elicited, point tenderness is almost universal, and in more superficial areas, edema, warmth, ecchymosis, or even a palpable callus may be present (Mayer et al., 2014).

Medial Ankle Sprain: The deltoid ligament complex (DLC) is the primary medial ligamentous stabilizer of the ankle. In athletic settings, this injury typically occurs as a result of contact with another player. Collegiate men’s and women’s soccer, men’s football, and women’s gymnastics have the highest incidence of medial ankle sprain (Chen et al., 2019).

Torn Achiles: Achilles’s tendon rupture is the most common tendon rupture in the lower extremity. The injury most commonly occurs in adults in their third to fifth decade of life. Acute ruptures often present with sudden onset of pain associated with a “snapping” or audible “pop” heard at the site of injury. On physical exam, patients with Achilles’s tendon rupture are unable to stand on their toes or have very weak plantar flexion of the ankle (Shamock & Varcallo, 2021). Thompson Test performed to determine tendon ruptures.

Calcaneus Fracture: The hindfoot articulates with the tibia and fibula creating the ankle joint. The subtalar or calcaneal joint accounts for at least some foot and ankle dorsal/plantar flexion. Calcaneal fractures most commonly occur during high energy events leading to axial loading of the bone but can occur with any injury to the foot and ankle. Patients will present with diffuse pain, edema, and ecchymosis at the affected fracture site (Davis et al., 2021). The patient is not likely able to bear weight. Bohler’s Angle may be depressed on plain radiographs.