Feb 23, 2024 ASSESSING MUSCULOSKELETAL PAIN NURS 6512
ASSESSING MUSCULOSKELETAL PAIN NURS 6512
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 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).
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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
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.
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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.
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
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. SAMPLE 2 Name: Ashley Silver Section: NURS 6512-28 Week 8: Assessment of the Musculoskeletal System Case Study 2 Patient name: Angel Rodriguez Age: 46 Gender: Female Ethnicity: Hispanic Angel Rodriguez is a 46-year-old Hispanic female with complaints of pain in both of her ankles, but more pain and concern about the right ankle. She heard a “pop” when she was playing soccer this past weekend. She has the ability to bear weight, but expresses some discomfort. SUBJECTIVE DATA: Chief Complaint (CC): “I have pain in both my ankles, but more in the right.” History of Present Illness (HPI): AR is a 46 years-old-female who presents to the clinic for bilateral ankle pain for 3 days. The pain started after she was playing soccer over the weekend and noticed a “pop” sound while playing. She reports the pain as “throbbing, sore, and sharp.” She can bear weight on both ankles but the pain is worse on the right. Her pain is a 6/10 on the severity scale. The pain increases to a 9/10 on the right ankle when ambulating or standing for an extended amount of time. AR has been elevating her ankles on pillows and applied heat and ice packs with no relief. She reports her right ankle is swollen and tender to touch. Currently her pain is 3/10 on the left ankle and 8/10 on the right ankle. Current Medications Multivitamin PO daily- name unknown Ibuprofen 800 mg Q6 PRN for pain Tylenol 650 mg Q6 PRN for pain Allergies: No drug, food, seasonal, or animal allergies. Past Medical History (PMH): No recent hospitalizations were reported. Broke left wrist in May 2015. Osteoporosis at age 45. Past Surgical History (PSH): No surgery history. Sexual/Reproductive History: Last menstrual cycle was 3 weeks ago. Engaged to fiance for 8 months. Fiance is AR’s only sexual partner. Personal/Social History: AR’s occupation is a Recreational Therapist at University of Chapel Hill (UNC)- Nash for 5 years. Her fiance and her own their home for the past year. They only share their home with 2 dogs. Rodriguez enjoys playing soccer, reading, shopping, and volunteering at her neighborhood garden. She drinks 2-3 glasses of wine every weekend. She denies smoking tobacco/vapes and illicit street drugs. Immunization History: Influenza: 09/13/2022. 46 years old. Hep B: 3 dose series completed at 6 months old. Hep A: 2 dose series completed at 15 months old. Pneumococcal: 4 dose series completed at 15 months old. DTaP: 5 dose series completed at 6 months old. MMR: 2 dose series completed at 6 months old. Varicella: 2 dose series completed at 6 months old. Polio: 4 dose series completed at 7 months old. Significant Family History: Mother- age 76, DM2, HTN, HLD, Father- age 74- tobacco smoker, HTN, COPD Maternal Grand-mother- deceased- age 88- CVA Maternal Grand-father- deceased- age 86- MI, tobacco smoker, COPD, HTN Paternal Grand-mother- age 87- HTN Paternal Grandfather- deceased- age 85- CVA ROS: General:Reports feeling fatigued and “extra tired” from ambulating/bearing weight on her ankles. Reports lack of sleep due to pain. HEENT: Head:No headaches reported. Denies dizziness. Eyes:Denies problems with eyes. Denies eye itching, redness, watery or pain. Does wear reading eyeglasses. Ears: No history of frequent ear infections. Denies ear surgery history. Denies ear pain, no swelling or drainage from bilateral ears. Denies hearing difficulties. Denies ear popping. Nose:Denies runny nose, bleeding, or pain. Denies sinus pain. Throat:Denies sore throat pain and coughing every few minutes. Denies discolored sputum. Cardiovascular:Denies chest pain, tightness, and palpitations Respiratory:Denies shortness of breath, wheezing, and cough. Musculoskeletal:Denies history of arthritis, limited range of motion. Positive for right ankle swelling, tenderness to touch, pain 9/10. Left ankle full range of motion, no signs of swelling or tenderness, pain 3/10. Objective: VS: B/P:120/84 T-98.7 F P-80 R-20 SPO2 -100%RA Weight: 200 lbs. Height: 5’ 8’’ ft General: AAOx4, cooperative, calm, appropriate to age. Able to answer all questions appropriately. Appears fatigued and grimaces facial expressions. HEENT: Head: Normal size and shape, hair evenly distributed, no masses. Cardiovascular/ Peripheral Vascular: S1 and S2 heard on auscultation, no murmurs or extra heart sounds. Right ankle with ecchymosis. edema, tender, and warm to touch. Left ankle no edema or ecchymosis. Bilateral posterior tibial pulses 2+ No thrill. Bilateral dorsalis pedis 2+ pulses no thrill. Capillary refills in digits and phalanges less than 3 seconds. Respiratory: Clear breath sounds present in all lung fields. No shortness of breath observed. No posterior/anterior masses, bulges, or crepitus felt on palpation. No adventitious breath sounds on auscultation. Skin: No lesions, bruises, or bumps. Ecchymosis noted on the right ankle. Muskuloskeletal: Right ankle edema with 4X4 cm ecchymosis on mid-lateral malleolus area with tenderness upon palpation on the lateral side. Active range of motion with pain bilateral ankles and limitation with dorsiflexion, plantar flexion, and inversion. Positive pain on rotation of ankles bilaterally with worsen pain on right. No bony tenderness, deformity, or crepitus. Diagnostic Results X-Ray: Internal/external rotation of bilateral ankles Anterior/posterior drawing test: applied to assess the integrity of ATFL as it prevents anterior translation of the talus under the distal tibia. Ten millimeters of displacement in the injured ankle or more than 3-4 mm of difference in translation compared with the healthy side indicate an ATFL tear.In an ATFL tear, a dimple sign may also be visible in the anterior side of the joint in 50% of cases anterior and posterior cruciate ligament integrity (Halabchi & Hassabi, 2020) Talar tilt test: evaluates the integrity of the CFL. In this test, the angle between the talar dome and the tibial plafond is measured during forced heel inversion while the tibiotalar joint is in the neutral position. If there is more than 5° of difference with the normal side, the test is considered positive (Halabchi & Hassabi, 2020) ASSESSMENT Angel is having persistent pain in bilateral ankles, more in right than left. With her past medical history of fractured left wrist, there could be an underlying etiology that needs short- term treatment and follow up appointments. With Angel working as a Recreational Therapist and playing soccer for leisure, she is up on her feet the majority of the time. Therefore, diagnosing and treating Angel’s chief complaint is crucial. Differential Diagnoses: Ankle fracture- Can be a partial or complete break in the bone. Most likely caused by direct or indirect trauma. Patients can complain of being unable to bear weight at all for extended periods of time, swelling, pain, and limited movement. Felt a “pop” or “snap” with injury (Ball et al., 2019). Site appears swollen, deformity, tender to touch, or deformity. Ankle sprain- Acute ankle spra
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