Feb 23, 2024 Discussion: Assessing Musculoskeletal Pains
Discussion: Assessing Musculoskeletal Pains
Discussion Assessing Musculoskeletal Pains
Subjective
CC: Lower back pain
HPI: Hispanic male patient JM, age 42, presented to the clinic today complaining of severe lower back pain over the past month. Periodically, the pain travels along his left leg. He felt a sharp, throbbing pain in his left lower leg, along with a tingling feeling. He said the ache in his back was an eight out of ten. He feels more discomfort when he lifts heavy objects, bends, or sits for lengthy periods of time. He says over-the-counter ibuprofen helps a little.
Current Medications:
OTC Ibuprofen 400mg Q4hrs as needed for pain.
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Claritin 10mg daily for allergies
Lisinopril 5mg daily for hypertension
Allergies: No known drug allergy; environmental allergies: Pollen (Reaction- sneezing and watery eyes).
PMHx: Medical history includes hypertension 5 years ago. No hospitalizations. His vaccinations are all current.
Past surgical Hx: No surgical history reported.
Social Hx: JM has a high school diploma and is employed as a bricklayer for a local construction company. He is married and resides in a three-bedroom home with his wife and 10-year-old son. For the last ten years, he has been smoking one pack of cigarettes per day. He denied consuming alcohol or using illegal substances. Because of his back pain, he refuses to exercise on a regular basis. He follows a healthy diet that includes fruits and vegetables.
Family Hx: Mother is 65 years old, living, and has been diagnosed with high blood pressure and
Discussion Assessing Musculoskeletal Pains
high cholesterol. His father is 70 years old, living and suffering from hypertension and benign prostatic hyperplasia. Grandpa on the mother’s side passed away at age 64 due to heart attack complications. Maternal grandmother died at age 73 from asthma and diabetes related problems. His paternal grandfather passed away at age 71 due to COPD-related illnesses. His paternal grandmother was 55 years old when she passed away from lung cancer. At the age of 45, one sibling was diagnosed with multiple sclerosis. One healthy kid of 10 years old.
ROS:
General: Reported intermittent tingling and numbness in the left limb. No reports of fever, chills, or weight loss.
HEENT: Denies head injury, blurred vision, hearing loss. No changes in smell or taste reported. No complaints of epistaxis. No sore throat was reported.
Skin: No skin lesion, mole, or rash.
Cardiovascular: No reports of heart murmur, chest discomfort, and irregular heartbeat. No edema in the extremities.
Respiratory: No reports of cough or dyspnea.
Neurological: Denies migraines, fainting, or convulsions. No reports of coordination problems.
Musculoskeletal: Pain in the lower back and sometimes in the left leg. Denies that other parts of the body have swollen joints or muscle pain.
Hematologic/Lymphatic: Denies bleeding or bruising. Denies enlarged nodes or history of splenectomy.
Endocrine: No heat or cold intolerance reported. No c/o polydipsia or polyuria.
Objective
Physical Exam:
General: Patient is alert and oriented x3. He is calm and answers interview questions appropriately. He is well-nourished and well- developed. He reports weakness to the left lower extremity.
Vitals: BP- 145/88mmHg; HR- 90bpm and regular; Resp- 19bpm and regular; Temp- 98.5F orally; SPO2 99%R/A; Height- 5’8”; Weight- 166lbs; BMI- 25.2.
Skin: Turgor is good. No rashes or lesions.
HEENT: Head is normocephalic. PERRLA. Conjunctivae negative for exudate and hemorrhage. External auditory canal is patent. Ears are nontender and not swollen. Nares are patent. Nasal mucosa is pink without drainage. Oral mucosa is moist, pink with no lesions. No tonsillar swelling, no pharyngeal swelling.
Cardiovascular/peripheral Vascular: Presence of S1S2 heart sounds during auscultation; no murmurs. Heart rate regular rhythm. Peripheral pulses 2+ symmetrical bilaterally. No peripheral edema.
Respiratory: Chest symmetrical. No adventitious lung sound auscultated.
Gastrointestinal: Abdomen is symmetrical. Normoactive bowel sounds x four quadrants. Abdomen is soft, nontender. No palpable masses.
Musculoskeletal: Low back pain with flexion, extension, and twisting. Limited ROM to lower extremities. No sign of trauma to lower back.
Neurological: Alert and oriented x3. Appropriate affect and mood.
Diagnostic Test:
Complete blood count (CBC) to verify infection (high WBC count).
Erythrocyte sedimentation rate (ESR) to detect inflammation.
A computed tomography (CT) scan to detect unusual tissues and analyze the patient’s spinal status.
Imaging of the spinal cord and nerves using (MRI) magnetic resonance imaging (Dains et al., 2019).
Assessment
Differential Diagnosis:
Lumber disc herniation (LDH): Lumbar disc herniation is defined as the movement of disc material (annulus fibrosis or nucleus pulposus) over the intervertebral disc area, causing low back and/or leg pain (Yang et al., 2022). It usually starts with lower back discomfort that spreads down one leg and is often followed by sensations of numbness or tingling in the lower leg. The symptoms of LDH correspond to the patient’s chief concern.
Sciatica: Sciatica is characterized by radiating and tingling pain down the leg and lower back caused by inflammation or compression of the lumbosacral nerve roots (Jensen et al., 2019). Furthermore, sciatica is frequently brought on by a herniated spinal disk, excessive movement, or heavy lifting, according to Dains et al. (2019). The patient is overweight, and his job requires heavy lifting and recurrent movements, which may contribute to his lower back pain.
Lumber Spinal Stenosis (LSS): Lumbar spinal stenosis (LSS) is a degenerative disc condition that causes the area encompassing the vertebrae’s neurovascular systems to narrow (Fishchenko et al., 2018). Symptoms of nerve inflammation or compression include discomfort and weakness or numbness in the legs. A history, physical examination, and imaging studies are used to make the diagnosis. The assessment should concentrate on leg or buttock pain while ambulating and stretching to alleviate symptoms (Chagnas et al., 2019).
Piriformis Syndrome (PS): Muscle spasm in the piriformis and/or irritation of the sciatic nerve in the area are the root causes of piriformis syndrome, as stated by Siddiq & Rasker (2019). Physical examination, patient history, and imaging studies like x-rays are used to determine the diagnosis of PS. The authors indicated that the flexion-adduction-internal rotation test, the Pace sign, and the Freiberg techniques are used to identify individuals with PS. Pain and weakness by resisted abduction and external rotation of the hip while seated suggests signs of Pace. The Freiberg sign manifests as pain and weakness with passive forced internal rotation of the hip in a supine position.
Lumbar spondylolisthesis: Low back pain, lower limb radiating pain, and sporadic neurogenic claudication are symptoms of lumbar spondylolisthesis, a degenerative condition of the lumbar spine (Wang et al., 2022). The patient’s symptoms match the above statement, too.
References
Chagnas, M.-O., Poiraudeau, S., Lef vre-Colau, M.-M., Rannou, F., & Nguyen, C. (2019).
Diagnosis and management of lumbar spinal stenosis in primary care in france: A survey
of general practitioners. BMC Musculoskeletal Disorders, 20(1).
https://doi.org/10.1186/s12891-019-2782-y
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.
Fishchenko, I. V., Kravchuk, L. D., & Perepechay, O. A. (2018). Lumbar spinal stenosis: symptoms, diagnosis and treatment (meta-
analysis of literature data). Pain Medicine, 3(1), 18–32. https:// doiorg.ezp.waldenulibrary.org/10.31636/pmjua.v3i1.83
Jensen, R.K., Kongstead, A., Kjaer, P., & Koes, B. (2019). Diagnosis and treatment of sciatica. BMJ. 16273.
https://doi.org/10.1136/bmj.16273
Siddiq, M. B., & Rasker, J.J (2019). Piriformis pyomyositis, a cause of piriformis syndrome-a systematic search and review. Clinical
Rheumatology, 38(7), 1811-1821. https://doi.org/10.1007/s10067-019-04552-y
Wang, P., Zhang, J., Liu, T., Yang, J., & Hao, D. (2022). Comparison of degenerative lumbar
spondylolisthesis and isthmic lumbar spondylolisthesis: Effect of pedicle screw
placement on proximal facet invasion in surgical treatment. BMC Musculoskeletal
Disorders, 23(1). https://doi.org/10.1186/s12891-021-04962-7
Yang, S., Shao, Y., Yan, Q., Wu, C., Yang, H., & Zou, J. (2021). Differential diagnosis strategy
between lower extremity arterial occlusive disease and lumbar disc herniation. BioMed
Research International, 2021, 1–5. https://doi.org/10.1155/2021/6653579
The body is constantly sending signals about its health. One of the most easily recognizedsignals is pain. Musculoskeletal conditions comprise one of the leading causes of severelong-term pain in patients. The musculoskeletal system is an elaborate system ofinterconnected levers that provides the body with support and mobility. Because of theinterconnectedness of the musculoskeletal system, identifying the causes of pain can bechallenging. Accurately interpreting the cause of musculoskeletal pain requires anassessment process informed by patient history and physical exams.In this Discussion, you will consider case studies that describe abnormal findings in patients seenin a clinical setting.
To prepare:
By Day 1 of this week, you will be assigned to one of the following specific casestudies for this Discussion. Please see the “Course Announcements” section ofthe classroom for your assignment from your Instructor. Your Discussion post should be in the Episodic/Focused SOAP Note formatrather than the traditional narrative style Discussion posting format. Refer toChapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in theWeek 5 Learning Resources for guidance. Remember that all Episodic/FocusedSOAP 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 fromhttp://www.med-ed.virginia.edu/courses/rad/ext/5lumbar/01anatomy.html. Used with permissionof University of Virginia.A 42-year-old male reports pain in his lower back for the past month. The painsometimes radiates to his left leg. In determining the cause of the back pain, based onyour 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 differentialdiagnoses for acute low back pain? Consider the possible origins using the Agency forHealthcare Research and Quality (AHRQ) guidelines as a framework. What physicalexamination 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 ofVirginia.A 46-year-old female reports pain in both of her ankles, but she is more concerned abouther right ankle. She was playing soccer over the weekend and heard a "pop." She is ableto bear weight, but it is uncomfortable. In determining the cause of the ankle pain, basedon your knowledge of anatomy, what foot structures are likely involved? What othersymptoms 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?
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Case 3: Knee Pain
Photo Credit: University of Virginia. (n.d.). Normal Knee Anatomy [Photograph]. Retrieved fromhttp://www.med-ed.virginia.edu/courses/rad/ext/7knee/01anatomy.html. Used with permission ofUniversity 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 causesof the knee pain, what additional history do you need? What categories can you use todifferentiate knee pain? What are your specific differential diagnoses for knee pain?What physical examination will you perform? What anatomic structures are youassessing 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 thecase study. Consider what history would be necessary to collect from the patient in the case studyyou were assigned. Consider what physical exams and diagnostic tests would be appropriate to gather moreinformation about the patient's condition. How would the results be used to make adiagnosis?
Identify at least five possible conditions that may be considered in a differentialdiagnosis 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 wereassigned.
By Day 3 of Week 8
Post an episodic/focused note about the patient in the case study to which you were assignedusing the episodic/focused note template provided in the Week 5 resources. Provide evidencefrom the literature to support diagnostic tests that would be appropriate for each case. List fivedifferent possible conditions for the patient's differential diagnosis, and justify why you selectedeach.Note: For this Discussion, you are required to complete your initial post before you will be ableto view and respond to your colleagues’ postings. Begin by clicking on the "Post to DiscussionQuestion" link, and then select "Create Thread" to complete your initial post. Remember, onceyou 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 differentcase studies than you. Analyze the possible conditions from your colleagues' differentialdiagnoses. Determine which of the conditions you would reject and why. Identify the most likelycondition, and justify your reasoning.Submission and Grading Information
Grading Criteria
To access your rubric:Week 8 Discussion Rubric
Post by Day 3 of Week 8 and Respond by Day 6 of Week 8
To Participate in this Discussion:
Week 8 Discussion
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 musculoskeletalsystem. In addition, the authors explore the anatomy and physiology of themusculoskeletal system.Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessmentand clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.Credit Line: Advanced Health Assessment and Clinical Diagnosis in PrimaryCare, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019by Mosby. Reprinted by permission of Mosby via the Copyright ClearanceCenter.
Chapter 22, “Lower Extremity Limb Pain”This chapter outlines how to take a focused history and perform a physical examto determine the cause of limb pain. It includes a discussion of the most commontests 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. Itincludes 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" ("MuscleStrength Grading") (Previously read in Weeks 1, 2, 3, 4, and 5) Chapter 3, "SOAP Notes"This section explains the procedural knowledge needed to performmusculoskeletal procedures.Note: Download this Student Checklist and Abdomen Key Points to use duringyour 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 physicalexamination: An interprofessional approach (9th ed.). St. Louis, MO: ElsevierMosby.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 byElsevier Health Sciences. Reprinted by permission of Elsevier Health Sciencesvia 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 byElsevier Health Sciences. Reprinted by permission of Elsevier Health Sciencesvia 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-HispanicWhites with chronic back and knee pain: A qualitative study. BMCMusculoskeletal Disorders, 12(1), 78–85.
This study examines the medical decision making among Hispanicsand non-Hispanic whites. The authors also analyze the preferredinformation 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 painand 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 physicalactivity 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 diagnosticexamination (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, andextremities. The chapter also describes how to examine the spine, pelvis,and extremities.
Required Media (click to expand/reduce)
Musculoskeletal System – Week 8 (12m)
Online media for Seidel's Guide to Physical ExaminationIn addition to this week's resources, it is highly recommended that you access and viewthe 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 accessinstructions on https://evolve.elsevier.com/
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 fe
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