Discussion: Assessing Musculoskeletal Pain

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

Case 2: Ankle Pain

Case 3: Knee Pain

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.

Also Read;  SOAP NOTE WRITING SERVICES

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. 

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.

Submission and Grading Information

Grading Criteria

 Sample Discussion Post

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?

 

Patient Information:

 

J.G. Age 42 Caucasian Male

 

CC: “Lower Back Pain”

 

HPI: The patient is a 42-year-old white male who complains of lower back pain that started approximately 1 month ago. He states sometimes the pain radiates to his left leg. His lower back pain is increased with sitting or standing for long periods of time. Denies any fever, chills, and sweating.

 

Current Medications: Multivitamin 1 tab daily, Motrin 800 mg every 4 to 6 hours prn

 

Allergies: No known drug, food, or environmental allergies.

 

PMHx: Denies medical history

 

PSHx: Tonsillectomy 1978

 

Soc Hx:  J.G. is a junior-high school history teacher and a football and baseball coach. J.G. lifts weights at the gym 3-4 days a week. He is happily married and has 1 son (4 yrs) who has no health problems.

 

Personal/Social History: Patient denies ever smoking cigarettes. Denies any recreational drug use. Drinks alcohol 1 night on the weekends, usually 6 shots of whiskey.

 

Fam Hx: Mother alive, age 72-years-old-COPD and hypertension. Father alive-COPD, hypertension, and DM

 

ROS:

 

GENERAL:  Appears well groomed and well nourished. No weight loss. Complaint of lower back pain. No complaint of fever, chills, weakness, fatigue, constipation, bladder or bowel incontinence.

 

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 complaint of dyspnea, no cough.

 

GASTROINTESTINAL:  No nausea and vomiting. No diarrhea. No abdominal pain. No changes in bowel patterns.

GENITOURINARY:  No difficulty with urination, no urinary leakage or incontinence. No hematuria.

 

NEUROLOGICAL:  No headache, no dizziness, no syncope, no paralysis, no ataxia, no numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: complaints of lower back pain x 1month that radiates to left leg. Pain 7/10 sometimes increase pain when sitting or standing for long periods of time. States the pain is intermittent. Denies numbness. Pt states the pain is better after taking motrin. Patient denies any swelling, redness or heat at any of the joint sites.

 

HEMATOLOGIC: No anemia, bleeding or bruising.

 

LYMPHATICS: No enlarged nodes in the groin. No history of splenectomy.

 

PSYCHIATRIC: No history of depression or anxiety.

 

ENDOCRINOLOGIC: No complaints of fever, chills, and sweating.

 

ALLERGIES: No history of asthma, hives, eczema or rhinitis.

 

O.

 

Physical exam:

 

VS: BP 142/70; P 65; R 17; T 98.9F; O₂ SAT 99%; Wt. 195 lbs.; Ht 72”, pain 7/10 on scale of 0-10 at rest

 

General: Awake, alert, and oriented x4 male, well-groomed and well-nourished. Appears to be uncomfortable and in pain, with facial grimacing upon movement.

 

 Chest/Lungs: Lungs are clear to auscultation anteriorly and posteriorly with equal symmetry of chest rise and fall. Resonance noted to percussion bilaterally. No wheezes, rhonchi, or stridor. 

 

Cardiovascular: RRR without murmur. Good S1, S2. Radial and pedal pulses +2 bilaterally. No abdominal, carotid, or femoral bruits. No JVD. No edema of extremities noted. Capillary refill less that 3 seconds.

 

Abdomen: Soft. Nontender to palpitation. Normoactive bowel sounds in all 4 quadrants.

 

Musculoskeletal: Pt has full ROM of all extremities. No deformities of joints. Pain noted to left lower lumbar on palpitation. Pain radiating to left leg upon standing. Pain radiates all the way to left foot. Pt ambulatory without difficulty but does report pain to lower back.

 

Neurological: CN II-XII intact. Normal gait noted.

 

Skin: Warm and dry to touch. No ecchymosis or edema. No noted rashes, open wounds, or lesions. Hair is evenly distributed over scalp. 

 

Diagnostic tests/labs: 

 

Watch patient lay, sit, and stand to see if there are any difficulties in movement. Have pt walk to examine abnormalities in gait.

 

CBC and urinalysis: Used to confirm the diagnosis of infection or UTI

 

x-ray, CT, and/or MRI

 

Differential Diagnoses:

 

Lumbosacral Herniated Disc:  If a disc herniates and leaks some of its inner material, the disc can become aggravated to make daily life difficult and ultimately aggravating a nerve, triggering back pain and possibly pain and nerve symptoms down the leg (Härtl, 2016). This could result from the lifting of heavy objects (Ball, Dains, Flynn, Solomon, & Stewart, 2015) such as lifting weights like this patient does. Disc herniation causes nerve root irritation and produces acute low back pain that radiates down the buttock to below the knee (Dains, Baumann, & Scheibel, 2016).

 

Musculoskeletal Lumbar Strain: Most episodes of low back pain are caused by damage to the soft tissues supporting the lower spine, including muscles, tendons, and ligaments. The hip, pelvis, buttock, and hamstring muscles assist low back muscles in supporting the lumbar spine. When these muscles are injured, pain or tightness may be felt across the low back and into the hips or buttocks (Hamilton, 2017). A muscle strain could be caused by excessive stretching or forceful contraction beyond the muscle’s functional capacity. This could be associated with improper exercise warm up (Ball et al., 2015).

 

Lumbar Stenosis: Patients with lumbar spinal stenosis are typically comfortable at rest but cannot walk far without developing leg pain. For most people, symptoms of lumbar stenosis will typically fluctuate, with some periods of more severe symptoms and some with fewer or none, but symptoms are not always progressive over time. For each person, the severity and duration of lumbar stenosis symptoms are different (Ullrich, 2011). These patients my show a normal neurologic exam in the early stages but with progression, they may show lower extremity weakness and sensory loss (Ball et al., 2015).

 

Idiopathic Low Back Pain: Idiopathic back pain acknowledges the existence of real pain yet does not identify a particular or definitive cause. Some patients display horrible back pain, but there is no apparent anatomical source for the symptoms. Idiopathic pain is also a common diagnosis for patients who have not responded to traditional treatments. There is no apparent physical or psychological cause for the symptoms, therefore, the patient is left with no diagnosis (Danneskiold-Samsøe & Bartels, 2004). 

 

Spondylolisthesis: Spondylolisthesis has no neurological signs, but pain is localized to the lower back. This could be caused by rapid movement between hyperflexion and hyperextension (Dains, Baumann, & Scheibel, 2016).

 

Based on the patient’s presentation and x-ray, the diagnosis is musculoskeletal lumbar strain.