Feb 23, 2024 Assignment: Lab Assignment (Optional): Practice Assessment: Musculoskeletal Examination NURS 6512N-32
Assignment: Lab Assignment (Optional): Practice Assessment: Musculoskeletal Examination NURS 6512N-32
Assignment: Lab Assignment (Optional): Practice Assessment: Musculoskeletal Examination NURS 6512N-32
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
Examination
A description of symptoms alone is not enough to form an accurate diagnosis of
musculoskeletal conditions. Before forming a diagnosis, advanced practice nurses need
to perform a physical examination. Although the musculoskeletal examination is
relatively simple, it still needs to be performed multiple times before it can be mastered.
In preparation for the Comprehensive (Head-to-Toe) Physical Assessment due in Week
9, it is recommended that you practice performing a musculoskeletal examination this
week.
Note: This is an optional practice physical assessment.
To Prepare
Arrange an appropriate time and setting with your volunteer "patient" to perform a
musculoskeletal examination.
Download and review the Musculoskeletal Checklist provided in this week's Learning
Resources as well as review the Seidel’s Guide to Physical Examination online media.
The Lab Assignment
Perform the musculoskeletal examination. Be sure to cover all of the areas listed in the
checklist.
What's Coming Up in Week 9?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you will examine appropriate methods for assessing the cognition and the
neurologic systems during your Discussion. You also will complete the last assessment,
Comprehensive (Head-to-Toe) Physical Assessment. Once again, you will conduct this
assessment in the Digital Clinical Experience using the simulation tool, Shadow Health.
Make sure to plan your time accordingly.
Week 9 Required Media
Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images
Next week, you will need to view several videos and animations in the Seidel’s Guide to
Physical Examination as well as other media, as required, prior to completing your
Discussion. There are several videos of various lengths. Please plan ahead to ensure
you have time to view these media programs to complete your Discussion on time.
Next Week
To go to the next week:
Week 9
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Learning Resources
Required Readings (click to expand/reduce)
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.
Chapter 4, “Vital Signs and Pain Assessment” (Previously read in Week 6)
Chapter 22, “Musculoskeletal System”
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. (2019). Advanced health
assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., &
Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 22, “Lower Extremity Limb Pain”
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.
Chapter 24, “Low Back Pain (Acute)”
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. (2019). Guide to clinical documentation (3rd ed.).
Philadelphia, PA: F. A. Davis.
Chapter 2, "The Comprehensive History and Physical Exam" ("Muscle
Strength Grading") (Previously read in Weeks 1, 2, 3, 4, and 5)
Chapter 3, "SOAP Notes"
This section explains the procedural knowledge needed to perform
musculoskeletal procedures.
Note: Download this Student Checklist and Abdomen Key Points to use
during your practice abdominal examination.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Musculoskeletal system: Student checklist. In Seidel's guide to
physical examination: An interprofessional approach (9th ed.). St. Louis,
MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Musculoskeletal system: Key points. In Seidel's guide to physical
examination: An interprofessional approach (9th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
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.
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.
Smuck, M., Kao, M., Brar, N., Martinez-Ith, A., Choi, J., & Tomkins-Lane,
C. C. (2014). Does physical activity influence the relationship between low
back pain and obesity? The Spine Journal, 14(2), 209–216.
doi:10.1016/j.spinee.2013.11.010
Shiri, R., Solovieva, S., Husgafvel-Pursiainen, K., Telama, R., Yang, X.,
Viikari, J., Raitakari, O. T., & Viikari-Juntura, E. (2013). The role of obesity
and physical activity in non-specific and radiating low back pain: The
Young Finns study. Seminars in Arthritis & Rheumatism, 42(6), 640–650.
doi:10.1016/j.semarthrit.2012.09.002
Document: Episodic/Focused SOAP Note Exemplar (Word document)
Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s
diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
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.
Required Media (click to expand/reduce)
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/
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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