Feb 23, 2024 NURS 6512 Discussion Week 8: Assessing Musculoskeletal Pain
NURS 6512 Discussion Week 8: Assessing Musculoskeletal Pain NURS 6512 Discussion Week 8 Assessing Musculoskeletal Pain Discussion: Assessing Musculoskeletal Pain Thank you for the information. Sciatica pain is a typical symptom of Lumber disc herniation (LDH), but some neurogenic and malignant tumors surrounding the sciatic nerve also cause a similar sign. The essential factors in the pathogenesis of LDH are occurred because of intervertebral disc degeneration, trauma, and genetic and developmental abnormalities. LDH symptoms are low back pain, sciatica, muscle weakness, sensory deficits, and never root tension signs, while sciatic nerve-derived tumors and surrounding neoplasm also show similar symptoms (Zhao et al., 2021). Studies show that if patients present with back pain at rest, the possibility of tumors should be considered; proper imaging techniques should be used to prevent misdiagnosed with LDH. To avoid misdiagnosis, consistency between the clinical manifestation and radiological imaging findings, especially MRI results. According to Zhao et al., 2021, Sometimes sciatica caused by sciatic nerve tumors is only distal, without any radicular distribution. This pain is more severe than that caused by LDH, and this pain is not related to the position of the lumbar spine. Thus, performing a detailed physical examination of the sciatic nerve is beneficial to avoid this misdiagnosis. Degenerative lumbar spinal stenosis (DLSS) is most commonly due to degenerative changes in the Struggling to Meet Your Deadline? Get your assignment on NURS 6512 Discussion Week 8: Assessing Musculoskeletal Pain done on time by medical experts. Don’t wait – ORDER NOW! Meet my deadline NURS 6512 Discussion Week 8 Assessing Musculoskeletal Pain facet joint in an old individual. DLSS is a spinal canal narrowing that induces compression of the vascular structure and ischemia of the spinal nerves, leading to low back pain, leg pain, nervous claudication, disability, and loss of independence. Studies show that DLSS presented in up to 80% of adults aged 50 years or older. DLSS symptoms include pain in the groin, hips, and buttocks. DLSS impacted the ability to walk and move independently. DLSS can be diagnosed by MRI of the lumber spin, showing the atrophic muscles (Xia et al.,2021). Another diagnosis test – HLA-B27 -to determine the case of joint pain, stiffness, or swelling (blood test) Erythrocyte sedimented rate (ESR) – is a blood test for joint pain or arthritis and muscle symptoms. References Zhao, L., Wei, J., Wan, C., Han, S., & Sun, H. (2021). The diagnostic pitfalls of lumbar disc herniation—- malignant sciatic nerve tumor: two case reports and literature review. BMC Musculoskeletal Disorders, 22, 1-8. https://doi.org/10.1186/s12891-021-04728-1 Xia, G., Li, X., Shang, Y., Fu, B., Jiang, F., Liu, H., & Qiao, Y. (2021). Correlation between severity of spinal stenosis and multifidus atrophy in degenerative lumbar spinal stenosis. BMC Musculoskeletal Disorders, 22, 1-7. https://doi.org/10.1186/s12891-021-0 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. Episodic/Focused SOAP Note Template Case study 1: A 42-year-old male reports pain in his lower back for the past month Patient Information: CDD_42_M S. CC: pain in his lower back HPI: CDD is a 42-year-old male in the clinic today with c/o lower back pain for over one month. He states the pain radiates to his left leg at times. It has affected his work due to decreased mobility from the pain. Rates the current pain at a 6 out of 10. Has taken Ibuprofen 800mg twice daily for the past few weeks with little to no relief. Location: Lower back Onset: One month Character: Pain that radiates to his left leg. Associated signs and symptoms: Decreased mobility. Timing: Accelerates when walking Exacerbating/ relieving factors: Ibuprofen gives little to no relief Severity: 6/10 pain scale Medications: Lisinopril 10mg PO QD Ibuprofen 800mg Q6H PRN for pain in back Allergies: No known drug allergies Past Medical History (PMH): HTN Past Surgical History (PSH): None Sexual/Reproductive History: Married. Sexually active with wife. Two children, both in college and living away from home Personal/Social History: Non-smoker, does not drink, no illicit drug use Significant Family History: Mother-hx-HTN, DM Father-none Lifestyle: Electrician by trade, works in a local plant 40 hours a week. Active in the gym, goes several times per week. Married for over 15 years, two sons in college. Immunization History: His immunizations are up to date. TDap 2013. Influenza December 1, 2022. ROS: General: Denies fatigue, fever, chills, night sweats, and recent weight changes HEENT: No swelling in the throat. He denies throat pain. No abnormalities noted. Respiratory: Denies dyspnea, cough CV: Denies GI: Denies N/V/D GU: No change in his urinary pattern. Neuro: No syncopal episodes or dizziness, no paresthesia, headaches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history. Integument/Heme/Lymph: denies Endocrine: denies Allergic/Immunologic: No known drug allergies. O. Physical Exam: Vital signs: Temperature 98.6 Pulse 78 RR 18 BP 112/72 Weight 182lb Height 5’11 Neurological: awake, alert, oriented to person, place and time Skin: warm, dry, no breakdown noted Lungs: clear bilaterally Cardiovascular: regular rate, S1S2 present Abdomen: bowel sounds active x4 quadrants, no tenderness noted Peripheral vascular: No edema, pulses present and strong HEENT: no abnormalities noted Musculoskeletal: low back pain that radiates to left leg with mobility limitation. Denies history of arthritis, gout, and musculoskeletal injury Diagnostic results: X-Ray lumbar spine CT Cervical spine/lumbar spine A. Differential Diagnoses: Herniated lumbar disc-A herniated disk refers to a problem with one of the disks between the vertebrae that stack up to make the spine (Jordon et al., 2019). A herniated disk can irritate nearby nerves and result in pain, numbness or weakness in an arm or leg (Jordon et al., 2019). Diagnosis usually includes: CT lumbar spine, X-ray and an MRI. Sciatica- The sciatic nerve begins at your spinal cord, goes through the hips and buttocks, and then branches down each leg (Ropper & Zafonte, 2018). This nerve is the body’s longest nerve and one of the most important ones, as it has a direct effect on the ability to control the legs/feet (Ropper & Zafonte, 2018). Diagnosis is usually done with a physical exam that will include testing the muscle strength and reflexes to determine if pain is a result from doing so (Ropper & Zafonte, 2018). Also, a CT lumbar spine, X-ray and an MRI will be done. Muscle strain- Muscle strain is damage to a muscle or its attaching tendons (Orchard & Best, 2020). This can occur when putting extreme pressure on muscles during the course of normal daily activities, with sudden heavy lifting, during sports, or while performing work tasks (Orchard & Best, 2020). A physical exam is done, and possibly an X-ray to rule out other diagnosis. Resting, with the use of NSAIDs is the most common course of treatment (Orchard & Best, 2020). Spinal Stenosis- Spinal stenosis is a narrowing of the open spaces within the spine, which can put pressure on the spinal cord and the nerves that travel through the spine from the arms and legs (Melancia et al., 2018). Spinal stenosis occurs most often in the lower back and the neck. Spinal stenosis is most commonly caused by wear/tear changes in the spine related to osteoarthritis (Melancia et al., 2018). Ankylosing Spondylitis- Ankylosing spondylitis is an inflammatory disease that can cause some of the vertebrae in the spine to fuse together (Zhu et al., 2019). X-rays shows changes in joints and bones, though the visible signs of ankylosing spondylitis may not be evident early in the disease (Zhu et al., 2019). References Jordon, J., Konstantinou, K., & O’Dowd, J. (2019). Herniated lumbar disc. BMJ clinical evidence, 2019. Melancia, J. L., Francisco, A. F., & Antunes, J. L. (2018). Spinal stenosis. Handbook of clinical neurology, 119, 541-549. Orchard, J., & Best, T. M. (2020). The management of muscle strain injuries: an early return versus the risk of recurrence. Clinical Journal of Sport Medicine, 12(1), 3-5. Ropper, A. H., & Zafonte, R. D. (2018). Sciatica. New England Journal of Medicine, 372(13), 1240-1248. Zhu, W., He, X., Cheng, K., Zhang, L., Chen, D., Wang, X., … & Weng, X. (2019). Ankylosing spondylitis: etiology, pathogenesis, and treatments. Bone research, 7(1), 22. https://doi.org/10.1038/s41413-019-0057-8Links to an external site. 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. Patient Information: T.J., 15 years old, African American Male 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 “heterosexual”, but he is not sexually active. He lives with his parents. Denies any tobacco , alcohol, or illicit drug use. TJ is a high school student at Thomas Jefferson High school. He enjoys playing sports , football is his favorite sport. He is a wide receiver on the school football team. TJ runs in the morning and goes to the gym during the afternoons. TJ wears his seatbelt whenever riding in a motor vehicle , reports getting 8-10 hours of sleep a night. He likes spending time with his friends and going movies. Fam Hx: T.J parents are both still living. Dad 49 years old has history of HTN, Peptic ulcers, and gout . Mom 51-year-old has CHF and HTN. His younger brother does not have any significant health history. ROS: GENERAL: TJ does not have weight loss, denies fever, chills, weakness or fatigue. HEENT: Eyes: Denies blurred or loss vision. Denies double vision. No yellowsclerae noted. Ears, Nose, Throat: Reports no hearing loss, sneezing, congestion, runny nose or sore throat. SKIN: Denies rash or itching. CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. Denies palpitations or edema. RESPIRATORY: Denies shortness of breath, cough or sputum production. GASTROINTESTINAL: Denies intestinal discomfort, nausea, vomiting or diarrhea. Reports no abdominal pain or blood. GENITOURINARY: Reports No Burning on urination. NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. Reports no change in bowel or bladder control. MUSCULOSKELETAL: positive for bilateral patellar pain , tenderness, and slight edema around Right and left knee. HEMATOLOGIC: reports no anemia, bleeding or bruising. LYMPHATICS: denies enlarged nodes and history of splenectomy. PSYCHIATRIC: reports no depression or anxiety. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES: Denies history of asthma, hives, eczema, or rhinitis. O. Physical exam: Temp 98.6 F, Pulse 60, respirations 20and non labored. SPO2 100% on room air, BP 125/78mmhg. Weight 136 lbs, H5’8’’ Diagnostic tests: CT scan, MRI, and Xray. Blood Tests: CBC (inflammation and infection screening), Erythrocyte Sedimentation Rate(Inflammation screening) , Uric Acid (rule out gout), Rheumatoid Factor (rheumatoid factor) Differential Diagnoses Patellofemoral Pain Syndrome .The main cardinal feature of pain around anterior knee that worsens with descending stairs , squatting , and bending knee during weight bearing activities(Gaitonde, 2019). Patellar dislocation or Fracture . The main feature of this diagnosis is that occurs mostly in adults younger than 20 years old and accounts for more than 93% of the cases. It is usually the result of trauma or twisting tibia during physical activities(Ball, 2019), (Thijie,2019). Bursitis .It is an inflammation of the bursa that results in tenderness of the knee and knee pain. (Daines et al., 2019). Chondromalacia Patella(Runner’s knee) is a disease of the hyaline cartilage coating of the articular surfaces of the bone (Habusta et aal, 2019). Osgood-Schlatter Disease (OSD) – A condition in which the patellar ligament insertion on the tibial tuberosity ends up inflamed (Vaishya et al., 2018). References Gaitonde, D. Y., Ericksen, A., & Robbins, R. C. (2019). Patellofemoral Pain Syndrome. American family physician, 99(2), 88–94. https://pubmed.ncbi.nlm.nih.gov/30633480/ 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. ten Thije, J. H., &Frima, A. J. (2019). Patellar dislocation and osteochondral fractures. The Netherlands journal of surgery, 38(5), 150–154. https://pubmed.ncbi.nlm.nih.gov/3774187/ 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. Habusta, S., Coffey. R, Ponnarasu S, et al.(2022) Chondromalacia Patella. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459195/ Vaishya R, Azizi A, Agarwal A, et al.(2018) Apophysitis of the Tibial Tuberosity doi:10.7759/cureus.780 Submission and Grading Information Grading Criteria To access your rubric: Week 8 Discussion Rubric Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: NURS 6512 Discussion Week 8: Assessing Musculoskeletal Pain Post by Day 3 of Week 8 and Respond by Day 6 of Week 8 To Participate in this Discussion: Week 8 Discussion Thank you for sharing your discussion with us. Your assessment and outlining of the patient’s signs and symptoms indicate an assessment of patellar tendinitis. This is the most likely diagnosis for the patient based on the patient’s history of being an athlete and prior involvement in long jumping, which could have put excessive and repetitive strain on the knee and led to inflammation. Additionally, jumps and movements from basketball could also put additional stress on the knee resulting in pain complaints. Bursitis is also a condition secondary to tendinitis that has a similar presentation to that of the patient and is associated with overuse and trauma, leading to inflammation (Dains et al., 2019). It, therefore, is an appropriate diagnosis to examine and assess the patient to provide appropriate treatment. It is important to include it as a differential diagnosis as the location of the inflammation can differ. Therefore, treatment can be specifically directed to the inflamed location once a diagnosis is confirmed or ruled out. The diagnosis that is least likely for the patient from the assessment would be juvenile arthritis (JA). While JA is also an inflammation of the joint that can present as pain, the characteristics of the presenting complaint are not in line with the patient’s presentation. According to Dains et al.(2019), JA can also present with fatigue, low-grade fever, and weight loss. As outlined in your discussion, the patient does not present with these findings. The diagnosis is further less likely due to the differences in aggravation of symptoms. The patient reports worsening pain with intensive training, and after playing in games while in JA, the pain and stiffness are mostly noted in the night and morning and get better with activity. Swelling at the joint is also a common factor and was not present in this patient. JA is, therefore, the least likely assessment for this patient and the differential diagnosis I would reject. The patient’s history of sporting activity and athletic training does justify the inclusion of chondromalacia of the patella as a differential diagnosis. According to Habusta et al.(2022), patients with chondromalacia patella do present with pain as the most common presentation and is frequently seen in patients that experience post-traumatic injuries, wear and tear to the hyaline cartilage. The pain worsens with activities that increase stress on the patellofemoral joint, such as running and jumping, as outlined by the patient. Pain is a common symptom for most musculoskeletal conditions; therefore, it’s important to perform tests and diagnostics to rule out the possible cause of the pain
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