Assessing Musculoskeletal Pain Essay

The most common reason why patients call or visit the primary care provider is low back pain. This pain is characterized by muscle tension or stiffness localized in the region below the costal margin and above the gluteal folds, either with or without leg pain. Patients with this condition suffer from two challenging symptoms: severe pain and disability. Attempt to identify the real causative agent has been unsuccessful because it is associated with several factors. Assessing Musculoskeletal Pain Essay. Therefore, there can be a myriad of differential diagnoses that can be derived for the condition. However, musculoligamentous processes are usually suspected. Significantly for most patients, low back pain is not clearly explained or does not have a systematic pattern that predicts a particular disease (Atlas,2019). For instance, it is worthy to note that the patient might not suffer from ankylosing spondylitis despite presenting with back pain. The diagnosis manifests with joint stiffness, red eyes, blurred vision, and bone deformities (Bardin et al., 2017).

Your history-taking is impressive since you incorporated all the necessary information for the patient with lower back pain. The review of systems, too, shows the right selection of words and presents what you identified during the history taking. The physical examination is congruent with the essential musculoskeletal examination needed for the patient. Kindly note that it is crucial to perform a physical examination assessment of the sciatic nerve by asking the patient to raise his leg straight. Besides, your choice of diagnostic tests was excellent and relevant.

I agree with your primary diagnoses, and differential diagnoses of sciatica, spinal stenosis, and osteoporosis are among the highly likely diagnoses. Additional differential diagnoses include spinal compression, spinal disk herniation, and acute tendonitis. Spinal compression can result from a spinal tumor, injury to the spine, rheumatoid arthritis, or bone infections (Oliveira et al., 2018). The diagnosis’s symptoms include pain in the lower back and extremities. Assessing Musculoskeletal Pain Essay.

References

Atlas, S. J. (2019, October 24). Taming the pain of sciatica: For most people, time heals and less is more. Retrieved January 21, 2021, from https://www.health.harvard.edu/blog/taming-pain-sciatica-people-time-heals-less-2017071212048

Bardin, L. D., King, P., & Maher, C. G. (2017). Diagnostic triage for low back pain: a practical approach for primary care. Medical Journal of Australia, 206(6), 268-273.

Oliveira, C. B., Maher, C. G., Pinto, R. Z., Traeger, A. C., Lin, C. W. C., Chenot, J. F., … & Koes, B. W. (2018). Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. European Spine Journal, 27(11), 2791-2803.

Your analysis of the case study is entirely scientific and very informative. Patient’s history, review of systems and physical examination are detailed and ensure that all body systems are assessed. Physical examination, history taking and physical examination are essential tools of diagnosis because they provide a basis for investigating the cause of ill-health. Therefore, conducting a thorough physical exam and patient history is vital is getting the correct diagnosis of a patient. Assessing Musculoskeletal Pain Essay. Additionally, other assessment techniques such as those particular to the musculoskeletal system are perfect and help narrow the concern and make it easy to diagnose.

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Among the mentioned four techniques that you would consider to i.e. Talar tilt test, squeeze test, Ottawa ankle rule, and Bohler’s ankle.  I want to note that Ottawa ankle propose that ankle x-ray is only necessary when the patient is experiencing pain in the malleolar area and presents with any of the following symptoms; tenderness of the bones along 6cm posterior edge of fibular. Lateral malleolus bone tenderness along 6cm distal the posterior or the tip of the medial malleolus, inability to bear weight immediately after an incident or at the ED (Beckenkamp et al, 2017).

The additional differential diagnosis not captured in the paper include;

Assessment

• Anterior impingement (footballer’s ankle) – this is condition that presents with pain, irritation and limited movement of the ankle joint. (Jamwal, et al, 2017).
• Plantar fasciitis- the condition is more prevalent in women than in men, usually because of participating in weight-bearing stress sloppiness of the foot that exerts more weight on the medial and forward plantar (Jamwal, et al, 2017). Pain relievers when more weigh is on the heel
• Achilles tendinitis inflammation- this is the inflammation of the Achilles tendon and results into the following symptoms; pain, and swelling, on the injury site (Jamwal, et al, 2017). Patients often report a feeling of tightness with increasing difficulty in mobility.   

 

References

Beckenkamp, P. R., Lin, C. W. C., Macaskill, P., Michaleff, Z. A., Maher, C. G., & Moseley, A. M. (2017). Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis. British journal of sports medicine, 51(6), 504-510.

Jamwal, P. K., Hussain, S., Tsoi, Y. H., Ghayesh, M. H., & Xie, S. Q. (2017). Musculoskeletal modelling of human ankle complex: Estimation of ankle joint moments. Clinical Biomechanics, 44, 75-82. Assessing Musculoskeletal Pain Essay.

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.

 

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? Assessing Musculoskeletal Pain Essay.  

Focused SOAP Note: Right Ankle Pain

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.

What physical examination will you perform? What special maneuvers will you perform?

S.
CC: “Right ankle pain, playing soccer over the weekend and heard a “pop.”

HPI: The patient is a 46-year-old female with pain in both ankles, but while playing soccer she heard a “pop” and the right ankle is uncomfortable for her to bear weight on while standing.Assessing Musculoskeletal Pain Essay.  The pain is described as “uncomfortable” and is rated 5 out of 10 in terms of intensity. The pain is located in the right ankle. Reports able to tolerate pain. The patient took two Advil 200mg tablets at 0800 prior to the coming 1000 am appointment.
PMH: Obesity, PTSD
FH: Mother died at 32 car accident. Father obese, 68 alive.
SH: Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 20 years
ROS
General–Negative for fevers, chills, fatigue
Cardiovascular—Denies chest pain, dizziness or syncopal episodes.
Gastrointestinal–Denies nausea, diarrhea or constipation.
Pulmonary—Denies shortness of breath, chest trauma, or asthma.

O.

VS: BP 145/76; P 88; R 18; T 98.7; 02 98% Wt.  199 lbs.; Ht 62”

General–Pt appears in pain with bearing weight but able to independently transfer from w/c to exam table.

Cardiovascular— The chest is symmetric, with no scars.

No thrills associated.  Point of maximal impulse (PMI) noted at midclavicular line, in fifth intercostal space.

Normal S1 and S2, with regular rate and rhythm. No murmur.  No S3 or S4, no friction rub.

Gastrointestinal–The abdomen is symmetrical large round, no distention otherwise; bowel

sounds are normal in quality and intensity in all areas.

a bruit is heard in the right para-umbilical area. No masses or

splenomegaly are noted. Assessing Musculoskeletal Pain Essay.

Pulmonary— Lungs are clear to auscultation and percussion bilaterally

Musculoskeletal: Right foot ankle edematous with plantar based ecchymotic area and limited AROM, no bony tenderness at lateral and medial malleolus, no numbness or tingling in foot, able to bear weight and walk more than 4 steps in the exam room.

Skin: warm and dry with the pink oral mucosa, nail bed cap refill brisk <3 seconds upper and lower extremities. Right foot with the edematous ecchymotic plantar area, no skin tears, no bleeding.  

1. Diagnostic results: Right ankle x-ray 

Based on anatomy, the foot structures likely involved are ATFL, calcaneofibular ligament (CFL) & posterior talofibular ligament (PTFL) (Chen, 2019).

Other symptoms that need to be explored are tenderness over the posterior edge of the lateral and medial malleolus, and inability to bear weight immediately after time of injury and four steps at evaluation.

The ATFL will be tested with the anterior drawer test. by stabilizing the distal leg with one hand while the other hands grasp the calcaneus. With 20 degrees of plantar flexion, the examiner pulls forward on the calcaneus. Greater than 1 cm of translation of the foot compared with the uninjured leg suggests ligamentous laxity ( Myrick, 2018) Assessing Musculoskeletal Pain Essay.

The talar tilt test checks the lateral ankle ligaments for laxity, specifically calcaneofibular ligamentous laxity.  Stabilizing the distal leg in a neutral position and then invert the ankle. Compare the degree of inversion with the uninjured ankle (Sillevis et al., 2018)

The squeeze test could be done, looking for syndesmotic or high ankle sprain (Myrick, 2018).

The Ottawa ankle rules help with the determining the need to get a radiograph; a patient presenting with an ankle injury with pain near the malleoli and any of the following findings are true inability to bear weight both immediately and in the emergency department such as four steps in the examination area (Myrick, 2018). The Bohler’s angle is about 45 degrees is not suggestive of a calcaneus fracture and/or disruption of the posterior facet if she did not have pain near the malleoli, then there may not need to be an x-ray, but in this case patient-reported pain (Stapleton, 2014).

The examiner might explore osteoarthritis (OA) in this middle-aged female, with an erythrocyte sedimentation rate (ESR) and C-reactive Protein laboratory test (Chinese Orthopaedic Association, 2010). Assessing Musculoskeletal Pain Essay.

Primary Diagnosis/Presumptive Diagnosis:

Right Lateral Ankle Anterior Talofibular Ligament (ATFL) Sprain: because this accounts for 70% of lateral ankle sprains involve only this ligament and a mechanism of plantarflexion and inversion, ankles with pain likely due to being obese as noted in the majority of the middle-aged women with foot pain in the study noted in England (Gay, et al., 2014).

 

Differential Diagnosis:

1) Chronic Ankle Instability: Patients may have complaints of ankle pain after injury in the past ankle injuries (Chen, 2019).

2) Achilles tendinopathy: Often occurs with volleyball injuries and is an excessive motion of the hindfoot (Maffulli et al., 2004).

3) Osteoarthritis ankles with pain likely due to being obese as noted in the majority of the middle-aged women with foot pain in the study noted in England (Gay, et al., 2014).

1. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Chen, Y. (2019). Diagnosis and Treatment of Chronic Ankle Instability. In Ankle Injuries.

IntechOpen.

Chinese Orthopaedic Association (2010). Diagnosis and treatment of osteoarthritis. Orthopaedic

surgery, 2(1), 1–6. https://doi.org/10.1111/j.1757-7861.2009.00055.x

Gay, A., Culliford, D., Leyland, K., Arden, N. K., & Bowen, C. J. (2014). Associations between

body mass index and foot joint pain in middle-aged and older women: a longitudinal

population-based cohort study. Arthritis care & research, 66(12), 1873–1879.

https://doi.org/10.1002/acr.22408

King, L. K., March, L., & Anandacoomarasamy, A. (2013). Obesity & osteoarthritis. The Indian

journal of medical research, 138(2), 185–193.Assessing Musculoskeletal Pain Essay.

Maffulli, N., Sharma, P., & Luscombe, K. L. (2004). Achilles tendinopathy: etiology and

management. Journal of the Royal Society of Medicine, 97(10), 472–476.

https://doi.org/10.1258/jrsm.97.10.472

 

Myrick, K. M. (2018). Basics of Sports Injury Assessment. Manual of Men’s Health: Primary

 

Care Guidelines for APRNs & PAs.

 

Sillevis, R., Shamus, E., & van Duijn, A. (2020). Evaluation of anterotalofibular and calcaneofibular ligament stress tests utilizing musculoskeletal ultrasound Bottom of Form

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. 

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?  Assessing Musculoskeletal Pain Essay.  

Patient Information:

J.G, 42 y, M, W

S.

CC “Back Pain”

HPI: 42 year old W male presents with lower back pain for 1 month.  Patient states that pain is sharp and burning and sometimes radiates pain down his left leg.  Patient reports that he has been using Icy Hot patches on his lower back and using Icy Hot rub when the pain gets “too bad” with moderate relief.  He states that pain is relieved the most when he is at rest.  Currently his pain is 0/10 but when active 7/10.

Current Medications: Icy Hot back patches and Icy Hot rub as needed over the course of the month(purchased from CVS)

Allergies: Allergic to Iodine Contrast and Shellfish, causes hives and angioedema

PMHx: Does not receive Influenza vaccine, up to date on other immunizations

Soc Hx: Patient works in shipping and handling at FedEx for 20 years.  Hobbies include watching football on weekends with his 2 sons, and hunting when deer are in season.  Patient is divorced.  Smokes ½ a pack of cigarettes daily for 25 plus years, drinks a 6 pack of beer on weekends.  Patient lives alone and shares custody with his ex-wife.  Patient’s sister lives locally, parents living in Ohio.

Fam Hx: Patient reports parents are in good health however have “aides” that come in to cook their meals and help with tasks around the house.  Father had an MI sometime in his 50s.  Patient is unsure of the causes of death for his paternal grandparent; Maternal grandfather died from “drinking too much”, Maternal grandmother had HTN, Diabetes, Asthma, died from a “bad case of pneumonia”.  Oldest son, 21 is in college, has ADHD but no other health issue.  Youngest son, 15, has bouts of depression stemming from divorce, not diagnosed.

ROS:

GENERAL:  Patient has gained weight, not sure of how much; no fever, chills, fatigue.  Weakness and pain in lower back.No weight loss, fever, chills, weakness or fatigue.

HEENT:

Eyes:  No visual loss or blurred vision.  Does not wear eyeglasses, no history of trauma.

Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

GASTROINTESTINAL:  No anorexia, nausea, vomiting, constipation or diarrhea. No abdominal pain or blood noted in stool.

GENITOURINARY:  No difficulty urinating, no burning or hesitation, no nocturia.No Burning on urination.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis.  Sharp, burning pain that radiates to left foot and ankle.

MUSCULOSKELETAL:  Lower back pain, sharp burning pain that radiates down left leg to foot and ankle.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ALLERGIES:  Contrast iodine and shellfish cause hives and angioedema.

O.

Physical exam:

Head:

Eyes: PERRLA

Neck: Symmetrical, no masses palpated

Musculoskeletal:

Hands:  Strong bilateral grasp, radial, brachial+3 pulses

Feet:  Strong bilateral dorsiflexion and plantar flexion, posterior tibial, dorsalis pedis +3 pulses, Pain 8/10 left foot    when performing ROM

Spine: Rates pain 9/10 on palpation of lower back, no bruising or trauma noted on skin; Pain 10/10 when leaning forward to touch toes

Legs: Normal gait and stance, femoral, popliteal + 3 BL, Diminished reflexes left leg

Neurological: Alert and Oriented x4

 

Diagnostic results: CRP, ESR, and WBC for inflammation

Bone Graph

MRI

EMG

Sitting Leg Extension

Straight Leg Raises

FABER test

A.

Differential Diagnoses 

Sciatica- nerve root compression, relief with sitting, sharp burning pain that radiates posteriorly or laterally to foot or ankle; d/t repetitive motion strain, lifting, twisting, and bending.  EMG would show damage/inflammation at L5 and S1, Sitting knee extension and straight leg raises cause severe pain.

Ankylosing Spondylitis- Pain is worse in the morning and relieved with activity, usually seen in patients younger than 40, ESR and Spinal radiographs confirms diagnosis.  This patient’s pain worsens with activity.

Spinal Stenosis- Pain gets worse throughout the day, relieved with rest.  Presents like osteoarthritis of joints and some neurological symptoms.  MRI confirms diagnosis.  Some pseudoclaudication.  Questioning patient on neuro symptoms or any other joint pain.

Osteoporosis- This pain is chronic,  seen in many patients that are inactive. Tenderness over areas of compression fractures, loss of height.  Assessing Musculoskeletal Pain Essay. Bone scans and other spinal radiographs to see if there are fractures.

Tumor- Progressive pain that does not go away, occurs at night and at rest.  Fever, weight loss, tenderness near site of tumor.  A history of cancer is not known from the patient’s paternal grandparents, not found in maternal grandparents or parents.

 

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Atlas, S. J. (2019, October 24). Taming the pain of sciatica: For most people, time heals and less is more. Retrieved January 21, 2021, from https://www.health.harvard.edu/blog/taming-pain-sciatica-people-time-heals-less-2017071212048

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.

de Fermentier, P. (2018). Sciatica: definition, main causes and forms of natural therapy treatments. Journal of the Australian Traditional-Medicine Society, 24(4), 238–241.

Missenard, G., Bouthors, C., Fadel, E., & Court, C. (2020). Surgical strategies for primary malignant tumors of the thoracic and lumbar spine. Orthopaedics & Traumatology: Surgery & Research, 106(1), S53–S62. https://doi-org.ezp.waldenulibrary.org/10.1016/j.otsr.2019.05.028

Case Scenario: 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?

CC (chief complaint): bilateral dull knee pain

HPI: the patient is a 15 year old who presented with bilateral dull knee pain that has lasted for two months. The pain is associated with a catchy patella sensation, unilateral or bilateral knees click. He reports no other associated symptoms. However,  the pain is aggravated by bearing weight on one or both knees and exertion and doesn’t seem to get relief  with naprozen  or  other NSAIDS. He rates the pain severity at 7/10.

Current Medications: Naproxen  220mg x 2 tablets PO q 4hr PRN, Tylenol 225mg x 1-2 tablets PO Motrin 200mg x 2 tablets PO q 4hr PRN (alternating as needed for swelling & pain),

Allergies: No known food and drug allergy;

PMHx: All childhood immunization is up to date (MMR, Polio, DTaP/DT/Td, Hib, Hep B); no surgical history. No history of chronic illness.

Soc Hx: CK is a highly active student who plays basketball, who is the most dependable player in the team. Also commutes to school every day with his bicycle, which he adores so much. He resides with his family at an apartment in a subdivision 3 miles away from school. AB’s room is upstairs.  No history of alcohol and tobacco use.

Fam Hx: CK’s Dad is 40 years old with a history of knee replacement last year 3 months ago. Sometimes experiences pain and takes NSAIDs. Paternal Grandfather- 65 years, was a baseball player who left his career just at 23 years because of severe knee injuries. He had both partial and total knee replacement.

ROS:

GENERAL: patient stable, no fever, chills, weakness and or fatigue.

HEENT: Eyes – proper vision with no identifiable double vision, blurred vision, or yellow sclerae; Ears – no build-up or hearing loss, Nose & Throat – no sneezing, nasal congestion, and running nose. Assessing Musculoskeletal Pain Essay.

SKIN: skin is intact with no rashes or itching. Skin is moist, cool and has a normal turgor.

CARDIOVASCULAR: normal heart sounds heard, normal capillary refill. No chest pain voiced. No palpitations or edema noted. No murmurs noted.

RESPIRATORY: normal lung sounds, normal breathing pattern, lungs expand and contract symmetrically bilaterally. No cough.

GASTROINTESTINAL: bowel sounds present in all the quadrants, no inflammation, stool normal, not bloody. No pain, nausea, vomiting or diarrhea. No acid reflux, no tenderness noted.

GENITOURINARY:  Bright yellow color of urine with no episode of burning or pain on urination. No urinary incontinence. No history of blood in the urine.

NEUROLOGICAL: No headache or dizziness. The patient complains of tingling hands or feet when sitting or lying on them.

MUSCULOSKELETAL: Pain and Swelling in bilateral knees at times. No history of back pain and in upper extremity joints.

PSYCHIATRIC: General anxiety related to unending pain on the knee and the fear for a surgical operation. No history of psychotic disorders like depression.

ALLERGIES: the patient has no history of eczema, asthma, and or rhinitis. No known food and drug allergies.

O

Physical exam:

MUSCULOSKELETAL:

Pain and Swelling in bilateral knees. No upper extremity joints pain,

Diagnostic Tests: knee X-ray, patellar apprehension test, vastus medialis coordination test, waldron’s test, Clarke’s test, eccentric step test.

A.

Differential Diagnoses:

1)   Overuse injury – knee joint can suffer overuse when people are actively engaged in sporting activities. Usually, the knee joint has an attachment to tendons and several burses. The joint also has a patellofemoral joint which is significant in joint motion. DiFiori et al. (2016) describe that participation in vigorous physical activities causes joint overuse injury particularly among the youth and adolescent thus should be considered a differential. In some cases, patients can experience fractures of the joints.

2)   Soft tissue knee injury – Participation in any form of physical exercise may cause an injury on the knee. Injuries of the lower limb can easily be ignored when engaging in physical activity; even though it can be severe (Bramah et al., 2018). Therefore, patients complaining of knee pain needs to be assessed to ascertain if they have a soft tissue injury.

3)   Knee osteochondritis dissecans – Osteochondritis dissecans is a condition in which the blood flow to the bone is interrupted causing bone death. According to Bruns et al., (2018), the bone and the cartilage wears off, causing excess pain on the joint when in motion.  This can lead to early osteoarthritis (Perdisa et al., 2017) and must be considered a differential in this patient.

4)  Osgood-Schlatter disease – Osgood-Schlatter is a disease that is associated with growth spurts in children and adolescents. When pressure and exertion are applied on the knee, the bones and cartilage respond by an inflammation that is painful and interferes with movement (Circi et al., 2017). Since or the patient complains of bilateral knee pain and falls under the age bracket, a thorough investigation is necessary to rule out or confirm the diagnosis

5)   Patellofemoral joint syndromes – This is pain that is experienced in front of the knee joint due to excess participation in sporting activities. Usually referred to as ‘runner’s knee’. This disease is common among those participating in athletics and jumping games (Cedeno et al., 2018). Adolescents are usually engaged in sporting activities and can easily develop this condition. Therefore, performing an investigation for this particular condition will be significant in getting a diagnosis.

Primary Diagnosis: Patellofemoral Joint Syndrome

This disease is common among those participating in athletics and jumping game. As such, several clinical tests are available for the diagnosis of its diagnosis. X-ray, CT scan, and physical examination are the most commonly used techniques when diagnosing this disease (Breloff et al., 2019). Patients who report pain when performing eccentric step test show a positive sign for the condition. Fair banks apprehension test should be performed when the patient lies in a supine position, knee flexed to thirty degrees while the examiner pushes the patella in a lateral position. The patient may express apprehension through verbal expression and or involuntarily flexing the quadriceps muscle. Positive results from these two physical exams alongside radiology can be significant in the diagnosis of patellofemoral syndromes. Assessing Musculoskeletal Pain Essay.

References

Bramah, C., Preece, S. J., Gill, N., & Herrington, L. (2018). Is there a pathological gait associated with common soft-tissue running injuries?. The American journal of sports medicine, 46(12), 3023-3031.

Breloff, S. P., Dutta, A., Dai, F., Sinsel, E. W., Warren, C. M., Ning, X., & Wu, J. Z. (2019). Assessing work-related risk factors for musculoskeletal knee disorders in construction roofing tasks. Applied Ergonomics, 81, 102901.

Bruns, J., Werner, M., & Habermann, C. (2018). Osteochondritis dissecans: etiology, pathology, and imaging with a special focus on the knee joint. Cartilage, 9(4), 346-362.

Cedeno, E., & Papadakis, Z. (2018). Patellofemoral Pain Syndrome. In International Journal of Exercise Science: Conference Proceedings (Vol. 2, No. 10, p. 5).

Circi, E., Atalay, Y., & Beyzadeoglu, T. (2017). Treatment of Osgood–Schlatter disease: a review of the literature. Musculoskeletal Surgery, 101(3), 195-200.

DiFiori, J. P., Brenner, J. S., & Jayanthi, N. (2016). Overuse injuries of the extremities in pediatric and adolescent sports. In Injury in pediatric and adolescent sports (pp. 93-105). Springer, Cham.

Episodic/Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

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.

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 6^th edition formatting.

Focused SOAP Note for a patient with chest pain S. CC: “Chest pain” HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning.  The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms. PMH: Positive history of GERD and hypertension is controlled FH: Mother died at 78 of breast cancer; Father at 75 of CVA.  No history of premature cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years ROS General–Negative for fevers, chills, fatigue Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis O. VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”   General–Pt appears diaphoretic and anxious Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right inter-costal space which radiates to the neck. A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted. Assessing Musculoskeletal Pain Essay. Gastrointestinal–The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right para-umbilical area. No masses or splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation. Pulmonary— Lungs are clear to auscultation and percussion bilaterally   Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)   A. Differential Diagnosis: 1) Myocardial Infarction (provide supportive documentation with evidence based guidelines). 2) Angina (provide supportive documentation with evidence based guidelines). 3) Costochondritis (provide supportive documentation with evidence based guidelines).   Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction

 

1. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

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 3: Knee Pain

 

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? Assessing Musculoskeletal Pain Essay. 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 fivepossible conditions that may be considered in a differential diagnosis for the patient.

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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.

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. 

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.

 

Rubric

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	Excellent	Good	Fair	Poor
Main Posting	45 (45%) – 50 (50%) “Answers all parts of the Discussion question(s) with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources. Supported by at least three current, credible sources. Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.	40 (40%) – 44 (44%) “Responds to the Discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module. At least 75% of post has exceptional depth and breadth. Supported by at least three credible sources. Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.	35 (35%) – 39 (39%) “Responds to some of the Discussion question(s). One or two criteria are not addressed or are superficially addressed. Is somewhat lacking reflection and critical analysis and synthesis. Somewhat represents knowledge gained from the course readings for the module. Post is cited with two credible sources. Written somewhat concisely; may contain more than two spelling or grammatical errors. Contains some APA formatting errors.	0 (0%) – 34 (34%) “Does not respond to the Discussion question(s) adequately. Lacks depth or superficially addresses criteria. Lacks reflection and critical analysis and synthesis. Does not represent knowledge gained from the course readings for the module. Contains only one or no credible sources. Not written clearly or concisely. Contains more than two spelling or grammatical errors. Does not adhere to current APA manual writing rules and style.
Main Post: Timeliness	10 (10%) – 10 (10%) Posts main post by Day 3.	0 (0%) – 0 (0%) N/A	0 (0%) – 0 (0%) N/A	0 (0%) – 0 (0%) Does not post main post by Day 3.
First Response	17 (17%) – 18 (18%) “Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.	15 (15%) – 16 (16%) “Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.	13 (13%) – 14 (14%) “Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.	0 (0%) – 12 (12%) “Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Second Response	16 (16%) – 17 (17%) “Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.	14 (14%) – 15 (15%) “Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.	12 (12%) – 13 (13%) “Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.	0 (0%) – 11 (11%) “Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Participation	5 (5%) – 5 (5%) Meets requirements for participation by posting on three different days.	0 (0%) – 0 (0%) N/A	0 (0%) – 0 (0%) N/A	0 (0%) – 0 (0%) Does not meet requirements for participation by posting on three different days.

 

Total Points: 100

Assessing Musculoskeletal Pain Essay