Feb 23, 2024 Assignment: Assessing Muscoskeletal Pain Essay
Assignment: Assessing Muscoskeletal Pain Essay
Assignment: Assessing Muscoskeletal Pain Essay
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. 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).
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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.
This is an informative post. Patient assessment was important in establishing the reasons for pain and other possible underlying conditions. Another differential diagnosis I would suggest is lumbosacral muscle strains/sprains. This is a condition associated with traumatic episodes. The pain increases with movement and alleviates with a limited range of motion and rest. The development of low back pain can be associated with the sensitization of nerve endings by releasing chemical mediators, in-growth of neurovascular into the degenerated disk, and alteration in the biomechanical properties of the disk structure (Ma et al., 2019).
The development of an effective management plan in this case needs a refined subjective assessment to foster streamlining of physical examination. Interviewing the patient about the behavior of the symptoms and taking the history of the condition is vital in establishing the clinical rationale for the causal factors and causes of symptoms. The management plans frequent observation for regularity or reduction of pain, a sporadic repeat of CT scans and X-rays, and referring the patient to rehabilitation or a physical therapist for exercises (de Oliveira Silva et al., 2020).
References
de Oliveira Silva, D., Pazzinatto, M. F., Rathleff, M. S., Holden, S., Bell, E., Azevedo, F., & Barton, C. (2020). Patient education for patellofemoral pain: a systematic review. journal of orthopaedic & sports physical therapy, 50(7), 388-396. https://www.jospt.org/doi/10.2519/jospt.2020.9400
Ma, K., Zhuang, Z. G., Wang, L., Liu, X. G., Lu, L. J., Yang, X. Q., … & Liu, Y. Q. (2019). The Chinese Association for the Study of Pain (CASP): consensus on the assessment and management of chronic nonspecific low back pain. Pain Research and Management, 2019. https://doi.org/10.1155/2019/8957847
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No 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: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
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MUSCULOSKELETAL: No muscle, 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.
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: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.
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 to prevent misdiagnosis. Additionally, including the chondromalacia patella is important as it is sometimes diagnosed via the method of elimination.
References
Dains, J., Baumann, L., & Scheibel, P. (2019). Advanced health assessment & clinical diagnosis in primary care (6th ed.). St. Louis MO: Elsevier Mosby.
Habusta, S., Coffey, R., Ponnarasu, S., Mabrouk, A., & Griffin, E. (2022). Chondromalacia patella. StatPearls [Internet] Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459195/
Your post is well thought out and very informative. The conditions for consideration in CO’s case are patellofemoral pain syndrome, Osgood-Schlatter disease, patellar tendonitis, chondromalacia patella, and meniscal injury. Patellofemoral pain syndrome causes anterior knee pain. The pain is usually dull and worsened by exerting more pressure on the patellofemoral’s joint. Patel and Villalobos (2017) reveal that Osgood-Schlatter disease affects the growth plate of the tibia. They also show that chondromalacia patella hurts the cartilage below the kneecap (Patel & Villalobos, 2017). Then, the researchers denote patellar tendonitis to be an overuse injury that inflames the patellar tendon. Lastly, a meniscal injury is a tear to the meniscus. These conditions are synonymous with athletes who participate in sports that involve repetitive jumping or running.
Osgood-Schlatter disease and meniscal injury can be rejected as possible diagnoses. This is because the symptoms do not match the typical presentation of these conditions. According to Sanchez et al. (2022), Osgood-Schlatter disease usually causes pain and swelling below the knee joint, while meniscal injury typically causes joint line tenderness and locking or catching sensations.
Patellofemoral pain syndrome is the most probable condition here. The symptoms exhibited (bilateral anterior knee pain, clicking and catching under the patella, and aggravation of pain during running) are consistent with this condition. Also, the fact that the patient is a young male who participates in soccer and experiences relief with rest, ice application, and ibuprofen use supports this diagnosis. The physical examination findings, such as reduced range of motion and tenderness, also back this diagnosis. However, further imaging tests, such as X-rays or MRI, can be done to rule out other possible conditions and confirm the diagnosis of patellofemoral pain syndrome.
References:
Patel, D. R., & Villalobos, A. (2017). Evaluation and management of knee pain in young athletes: Overuse injuries of the knee. Translational Pediatrics, 6(3), 190-198. https://doi.org/10.21037/tp.2017.04.05Links to an external site.
Sanchez, S., Arlata, T., Arshad, S., Cheng, S., & Saunders, A. (2022, September 16). Knee injuries. The University of Texas Medical Branch. https://www.utmb.edu/pedi_ed/CoreV2/Musculoskeletal/Musculoskeletal5.htmlLinks to an external site.
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