Feb 23, 2024 Discussion: Assessing Muscoskeletal Pain
Discussion: Assessing Muscoskeletal Pain
Discussion: Assessing Muscoskeletal Pain
I enjoyed reading your post! In your episodic/SOAP note, you gave detailed information and painted a “realistic picture” of the patient. Recently, a medical doctor told me, “our bodies give us warning signs when it’s in distress. When the body is in distress, it tries to repair the issue. If the body does not repair the issue on its own, it’s up to healthcare professionals to figure out the etiology and treatment.”
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.
Case Study 3
In your assigned case study, the patient, PH, is a 15-year-old Filipino boy with complaints of bilateral knee pain for over a week. He describes the pain as dull intermittent “clicking” or “catching in one or both knees. PH reports that the pain started a couple weeks after basketball season started this year.
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PH stated he had pain similar to this last spring during track when he started competing in long jump. PH reports that it hurts more after practice than it does after a game stating, “coach has me doing extra running and jumping drills, he’s really hard on us.” He has a history of an ulnar fracture and multiple sprained ankles from basketball and track, but no previous knee injuries.
Patellar injury differential diagnosis- Patellar Tendonitis
Your differential diagnosis were Patellar Tendonitis, Chondromalacia of the Patella, Juvenile Arthritis, Bursitis, and Patellar Maltracking. Agreeably so, I believe Patellar Tendonitis is the primary diagnosis. Your description of the condition is best with PH reported signs and symptoms. Chronic inflammation, such as patellar tendonitis, leads to a weakened tendon and can increase the likelihood of tendon rupture. Certain medical conditions can lead to an overall weakened tendon and can also predispose an individual to tendon rupture such as patellar degeneration, overuse injury, and previous injury (Hsu & Siwiec, 20121).
Patellar injury differential diagnosis- Chondromalacia of the Patella
Chondromalacia of the Patella occurs with activity rather than a result of the activity. Chondromalacia patella (CMP) is when the posterior articular surface of the patella starts losing its density when in a healthy state and turns to be softer with subsequent tearing, fissuring, and erosion of the hyaline cartilage (Habusta et al., 2021). You stated that the condition is found more in women than men. According to (Habusta et al., 2021), CMP is more common in women than men and this is attributed to increased Q angles in women. Therefore, this will be a least likely primary diagnosis for PH since he is male gender.
Patellar injury differential diagnosis- Juvenile Arthritis
Juvenile Arthritis (JA), isn’t a specific condition. It is a broad term that describes numerous rheumatoid conditions in children. Similar to arthritis observed in adults, pathogenesis involves autoimmune and autoinflammatory mechanisms (Martini et al., 2022). Agreeably so, the majority of JA conditions are diagnosed at age 16 and older. One with JA can exhibit a fever, joint inflammation, swelling, pain and tenderness, but some types of JA have few or no joint symptoms or only affect the skin and internal organs (Arthritis Foundation, 2021). As you stated, it is least likely that PH has JA, but should not be completely eliminated until ruled out by further testing.
Patellar injury differential diagnosis- Bursitis
Bursitis does require treatment by a physician. The olecranon and prepatellar bursae are the most often involved sites, as their superficial location exposes them to injury. Among patients with bursitis, 80% are males aged 40 to 80 years who constitute the population most exposed to trauma and micro trauma during manual labor or recreational activities (Lormeau et al., 2019). PH unlikely has Bursitis due to the big gap in age and presenting symptoms. Therefore, I would eliminate this differential diagnosis.
Patellar injury differential diagnosis- Patellar Maltracking
Your last differential diagnosis was Patellar Maltracking. Patellar Maltracking refers to the dynamic relationship between the patella and trochlea during knee motion. Patellar maltracking occurs as a result of imbalance of this relationship often secondary to anatomic morphologic abnormality. Usually, young individuals, particularly women, suffer the consequences of this disorder (Jibri et al., 2019).
References
Arthritis Foundation. (2023). Juvenile Arthritis (JA). Retrieved January 17, 2023 https://www.arthritis.org/diseases/juvenile-arthritis
Habusta, S. F., Coffey, R., Ponnarasu, S., & Griffin, E. E. (2021). Chondromalacia patella. In StatPearls [Internet]. StatPearls Publishing.
Hsu, H., & Siwiec, R. M. (2021). Patellar tendon rupture. In StatPearls [Internet]. StatPearls Publishing.
Jibri, Z., Jamieson, P., Rakhra, K. S., Sampaio, M. L., & Dervin, G. (2019). Patellar maltracking: an update on the diagnosis and treatment strategies. Insights into imaging, 10(1), 1-11.
Lormeau, C., Cormier, G., Sigaux, J., Arvieux, C., & Semerano, L. (2019). Management of septic bursitis. Joint Bone Spine, 86(5), 583-588.Martini, A., Lovell, D. J., Albani, S., Brunner, H. I., Hyrich, K. L., Thompson, S. D., & Ruperto, N. (2022). Juvenile idiopathic arthritis. Nature Reviews Disease Primers, 8(1), 1-18.
Martini, A., Lovell, D. J., Albani, S., Brunner, H. I., Hyrich, K. L., Thompson, S. D., & Ruperto, N. (2022). Juvenile idiopathic arthritis. Nature Reviews Disease Primers, 8(1), 1-18.
S.
CC (chief complaint): “I feel pain in my ankles, but the right one is more intense.”
HPI:
R.K is a 46-year-old A.A female presenting with a chief complaint of pain in her ankles. She reports that the pain in the right ankle is more intense. The ankle pain began three days ago when she was playing soccer at the women’s soccer club in her church. She states that she heard a pop sound in her right ankle when playing, which was followed by a sudden intense pain on the right ankle, and she was unable to stand on the right foot. She has, however, been able to walk on the right foot, although it is uncomfortable. R.K also reports having some degree of tenderness and swelling on the right ankle. The ankle pain is aggravated by walking and relieved to some degree by OTC Tylenol, which she takes when the pain aggravates. She rates the pain on the left ankle as 3/10 and the right ankle as 6/10 on the pain scale.
Current Medications: OTC Tylenol 1 gm for pain.
Vitamin C supplements.
Allergies: Allergic to penicillin- causes rash, hives, and itchy eyes. No known food or seasonal allergies.
PMHx: Last Influenza shot-7 months ago. Last Tetanus- 3 years ago. No history of chronic illnesses. History of an appendectomy at 34 years. History of Tonsillectomy at 7 years.
Soc Hx:
R.K is a community youth counselor and has a diploma in Counseling. The patient is married. She currently lives with her spouse and three children aged 17, 14, and 8. Her hobbies include traveling and playing football. She is the captain of the women’s soccer club in her church and is the assistant coach for the junior girls’ soccer club. She reports taking wine occasionally but denies smoking tobacco or using illicit substances. She reports having a strict diet and taking about 7 glasses of water a day. The patient states that she has an active lifestyle and takes a morning run for about 40minutes at least 5 days a week. She also plays football on weekends. Her last health exam was 2 years ago. She states that her support system is her family and sisters.
Fam Hx: Family history of HTN- mother and maternal grandfather. History of breast cancer- paternal grandmother. The elder sister has a history of Asthma. Children are alive and well.
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ROS:
GENERAL: Denies elevated body temperature, reduced energy levels, chills, or weight loss/gain.
HEENT: No history of head trauma, visual changes, hearing loss, ear discharge, nasal discharge/blockage, sneezing, or pain/difficulty swallowing.
SKIN: Denies color changes, itching, or lesions.
CARDIOVASCULAR: No history of swelling, chest discomfort, heart palpitations, or dyspnea at rest or exertion.
RESPIRATORY: No history of chest pain, cough, sputum, or dyspnea.
GASTROINTESTINAL: Denies appetite changes, nausea/ vomiting, abdominal discomfort, or diarrhea/constipation.
GENITOURINARY: Denies abnormal PV discharge, dysuria, or urinary frequency/urgency. LMP-3 weeks ago.
NEUROLOGICAL: Negative for dizziness, headache, paralysis, or burning sensations in the extremities.
MUSCULOSKELETAL: Positive for ankle pain and swelling. Limitations in movement. Denies joint stiffness/pain/enlargement.
HEMATOLOGIC: No history of bleeding or blood transfusion.
PSYCHIATRIC: Denies history of mental illnesses.
ENDOCRINOLOGIC: Negative for excessive perspirations, cold/heat intolerance, excessive urination, or acute thirst.
ALLERGIES: Allergic to penicillin.
O.
Physical exam:
VITAL SIGNS: BP- 126/74; HR- 98; RR-20; Temp-98.78 F
HT-5’4; WT- 136 pounds.
GENERAL: Neat and well-groomed female in no acute distress. Alert and oriented X4. Speech is clear and goal-directed. Maintains eye contact and exhibits a positive attitude.
CARDIOVASCULAR: Negative for JVD or edema. RRR; S1and S2 audible. No gallop sounds or murmurs heard on auscultations.
RESPIRATORY: Smooth and uniform respirations. Chest clear on auscultation.
MUSCULOSKELETAL: No skin color changes at the ankles.
Left Ankle- No bruising, swelling, or loss of function. Mild tenderness at the anterior aspects of the lateral malleoli. Negative ligamentous laxity with anterior drawer and talar tilt testing. Decreased total ankle motion of 2 degrees. No bony point tenderness. No difficulty bearing weight.
Right ankle- Bruising present. Moderate tenderness at the maximal points of the anterior (ATFL) aspect of the lateral malleoli on the right ankle. Positive anterior drawer test, negative talar tilt test- moderate joint instability. Some loss of function. Decreased total ankle motion of 7 degrees. Pain with weight-bearing and walking. No bony point tenderness.
Diagnostic results:
X-ray of the right ankle: An X-ray will be required to exclude fractures.
The Ottawa ankle rules indicate that ankle radiographs should be obtained in the event of pain in the malleolar region and any of the following: Pain on the posterior margin of the distal 6 cm or apex of the lateral malleolus; Pain on the posterior margin of the distal 6 cm or apex of the medial malleolus; and Incapacity to bear weight right away after an injury and for four steps during the assessment (Wells et al., 2019).
A.
Differential Diagnoses
Acute Lateral Ankle Sprain
An ankle sprain entails an inversion-type twist of the foot, accompanied by pain and edema. Lateral ankle sprains are the most prevalent injury in physically active populations, primarily among teenagers and young adults (Herzog et al., 2019). Clinical features of ankle sprains include pain, tenderness, swelling, bruising, muscle spasm, and cold foot or paresthesia, which suggest possible neurovascular compromise (Herzog et al., 2019). According to Wells et al. (2019), ankle sprains are categorized as Grade I, II, and III. Grade I have minimal tenderness and swelling, no loss of function, decreased total ankle motion of 5 degrees and below, and swelling of 0.5 cm or below as measured by figure-of-eight testing.
Grade II is characterized by bruising, moderate tenderness, a decreased ROM between 5-10 degrees, moderate swelling of 0.5-2.0cm, and ankle instability (Wells et al., 2019). Grade III presents with bruising, significant swelling of greater than 2.0 cm, near-total loss of function, ankle instability, extreme point tenderness, and decreased ankle ROM > 10 degrees.
Acute Lateral Ankle Sprain is the presumptive diagnosis based on the positive findings in the right ankle, including bruises, some loss of function tenderness at the anterior aspect of the lateral malleoli, moderate joint instability, reduced ROM of 7 degrees, and pain with weight-bearing and walking. The right ankle symptoms are consistent with a grade II lateral ankle sprain.
Acute Achilles tendon ruptures
Individuals with an Achilles tendon rupture often present with a primary symptom of a sudden snap in the lower calf accompanied by acute, severe pain. According to Egger and Berkowitz (2017), Achilles tendon rupture commonly occurs in healthy, active, young- to middle-aged persons, mostly from 37 to 43.5 years old. Patients often report experiencing a popping or giving way feeling in their posterior heel after pushing off (Egger & Berkowitz, 2017). Immediate pain occurs but slowly resolves, leaving a person with difficulty with plantar flexion, weight-bearing, or limping. Besides, the person cannot stand their toes on the affected side (Egger & Berkowitz, 2017). Achilles tendon rupture is a differential diagnosis based on findings of ankle pain, popping sensation that occurred during the ankle injury, and difficulties with bearing weight.
Right Ankle Fracture
While lateral ankle sprains comprise 90% of all ankle injuries, whereas an ankle fracture occurs only in 15% of the injuries, ankle fractures occur due to a twisting mechanism sustained from a low-energy injury (Lawson et al., 2018). A fractured ankle presents with severe pain, swelling, ecchymosis, and soft tissue injuries, such as abrasions and lacerations. Other features include loss of function, limited range of motion, compromised neurovascular status, and positive talar tilt and drawer testing (Lawson et al., 2018). A Right Ankle fracture is a differential diagnosis based on pertinent positives of pain, bruising, loss of function, reduced ROM, and positive talar tilt and drawer testing indicating joint instability.
References
Egger, A. C., & Berkowitz, M. J. (2017). Achilles tendon injuries. Current reviews in musculoskeletal medicine, 10(1), 72–80. https://doi.org/10.1007/s12178-017-9386-7
Herzog, M. M., Kerr, Z. Y., Marshall, S. W., & Wikstrom, E. A. (2019). Epidemiology of ankle sprains and chronic ankle instability. Journal of athletic training, 54(6), 603-610. https://doi.org/10.4085/1062-6050-447-17
Lawson, K. A., Ayala, A. E., Morin, M. L., Latt, L. D., & Wild, J. R. (2018). Ankle fracture-dislocations: a review. Foot & Ankle Orthopaedics, 3(3), 2473011418765122. https://doi.org/10.1177/2473011418765122
Wells, B., Allen, C., Deyle, G., & Croy, T. (2019). MANAGEMENT OF ACUTE GRADE II LATERAL ANKLE SPRAINS WITH AN EMPHASIS ON LIGAMENT PROTECTION: A DESCRIPTIVE CASE SERIES. International journal of sports physical therapy, 14(3), 445–458. https://doi.org/10.26603/ijspt20190445
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Note: Your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to the Comprehensive SOAP Template in the attachments below for guidance.
CASE: 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?
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.
Address all these in the SOAP Note not an Narrative Essay (Follow the SOAP Note Template on the attachment):
1. A description of the health history you would need to collect from the patient in the case study to which you were assigned.
2. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.
3. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
4. Include how the patient X-ray helped you to refine the differential diagnosis
REMINDER:Please make a SOAP NOTE for this case. Make your own patient’s data, applicable health history, review of systems, P.E., labs, differential diagnosis, final diagnosis etc. Incorporate the data from the case in the SOAP note that you will do… This is not a narrative essay ok…. I need SOAP note (Nurse Practitioner/RN/MD makes SOAP note)… Be guided with the SOAP Note in the templates/exemplar… Don’t copy paste. Formulate your own… Don’t forget to cite the Five different possible conditions (Differential diagnosis) and have Reference lists too.
Resources:
· 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.
o Review of Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)
o Chapter 21, “Musculoskeletal System” (pp. 501-543)
This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system.
· Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
o Chapter 22, “Limb Pain” (pp. 356-374)
This chapter outlines how to take a focused history and perform a physical exam to determine the cause of limb pain. It includes a discussion of the most common tests used to assess musculoskeletal disorders.
o Chapter 24, “Low Back Pain (Acute)” (pp. 288-300)
The focus of this chapter is the identification of the causes of lower back pain. It includes suggested physical exams and potential diagnoses.
· Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
o Chapter 2, “The Comprehensive History and Physical Exam” (“Muscle Strength Grading”; p. 26)
o Chapter 4, “Pediatric Preventative Care Visits” (“Documentation of Important Components of Age Specific Physical Exams and Sports Pediatric Sports Participation Physical Exam”; pp. 78–79)
Note: Download this Adult Examination Checklist and Physical Exam Summary: Abdomen to use during your practice musculoskeletal examination.
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for musculoskeletal assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.This Adult Examination Checklist: Guide for Musculoskeletal Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Musculoskeletal system. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.This Musculoskeletal System Physical Exam Summary was published as a companion to Seidel’s guide to physical examination(8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Katz, J. N., Lyons, N., Wolff, L. S., Silverman, J., Emrani, P., Holt, H. L., & …Losina, E. (2011). Medical decision-making among Hispanics and non-Hispanic Whites with chronic back and knee pain: A qualitative study. BMC Musculoskeletal Disorders, 12(1), 78–85.Retrieved from the Walden Library databases.
This study examines the medical decision making among Hispanics and non-Hispanic whites. The authors also analyze the preferred information sources used for making decisions in these populations.
· Vismara, L., Menegoni, F., Zaina, F., Galli, M., Negrini, S., & Capodaglio, P. (2010). Effect of obesity and low back pain on spinal mobility: A cross sectional study in women. Journal of Neuroengineering & Rehabilitation, 7(1), 71–83.Retrieved from the Walden Library databases.
In this study, the authors explore the effect of obesity and chronic low back pain on spinal mobility. The authors use range of motion as a metric of spinal mobility.
· University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved fromhttp://www.med-ed.virginia.edu/courses/rad/index.htmlThis website provides an introduction to radiology and imaging. For this week, focus on skeletal trauma in musculoskeletal radiology.
Media
Online media for Seidel’s Guide to Physical Examination
In addition to this week’s resources, it is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapter 21 that relate to the assessment of the musculoskeletal system. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/.
Optional Resources
· LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowin’s diagnostic examination (9th ed.). New York, NY: McGraw Hill Medical.
o Chapter 13, “The Spine, Pelvis, and Extremities” (pp. 585–682)
In this chapter, the authors explain the physiology of the spine, pelvis, and extremities. The chapter also describes how to examine the spine, pelvis, and extremities.
Patient Information: T.J., 15 years old, African American Male
S.
CC “Both Knees hurt, especially when I walk upstairs. Sometimes I hear clicking sound along with this strange catching sensation under my knee”
HPI:
TJ is 15 -year-old African American male with bilateral patellar pain, dull in nature and localized around anterior knee area. The pain started 3 days ago and was associated with walking up and downstairs, running, and squatting. The knee pain frequently comes with a “clicking” noise and catching sensation under patella. Severity described as 7/10 .
Reports that Aleve makes it tolerable, but not completely better. Takes 1 caplet 220 mg q 8-12 hours. Exacerbating factors reported by the client are walking, jumping, and squatting.
Current Medications: Aleve 220 mg every 8-12 as needed for pain . No RX medications, no other over the counter medications.
Allergies:
No known allergies. Denies food , environmental and latex allergies.
PMHx:
Up to date on all his immunizations, last COVID booster in April 2022, last flu vaccine December 2021.
Fractured right tibia three years ago while playing football, Denies history of arthritis, rheumatic fever, or Lyme disease. Denies any prior surgeries and /or hospitalizations.
SocHx: TJ identifies himself as “
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