Vital Signs and Pain Assessment Discussion Paper

Case 1: Back Pain

Photo Credit: University of Virginia. (n.d.). Lumbar Spine Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/5lumbar/01anatomy.html. Used with permission of University of Virginia.
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? Vital Signs and Pain Assessment Discussion Paper

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HERE ARE SOME LINKS
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” Vital Signs and Pain Assessment Discussion Paper

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. Vital Signs and Pain Assessment Discussion Paper

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. Vital Signs and Pain Assessment Discussion Paper

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” Vital Signs and Pain Assessment Discussion Paper

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. Vital Signs and Pain Assessment Discussion Paper
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. Vital Signs and Pain Assessment Discussion Paper
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. Vital Signs and Pain Assessment Discussion Paper

Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., Ferreira, P. H., Fritz, J. M., Koes, B. W., Peul, W., Turner, J. A., Maher, C. G., Buchbinder, R., Hartvigsen, J., Cherkin, D., Foster, N. E., Maher, C. G., Underwood, M., van Tulder, M., . . . Woolf, A. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet, 391(10137), 2368–2383. https://doi.org/10.1016/s0140-6736(18)30489-6 Vital Signs and Pain Assessment Discussion Paper

Hicks, C., Levinger, P., Menant, J. C., Lord, S. R., Sachdev, P. S., Brodaty, H., & Sturnieks, D. L. (2020). Reduced strength, poor balance and concern about falls mediate the relationship between knee pain and fall risk in older people. BMC Geriatrics, 20(1), 94. https://doi.org/10.1186/s12877-020-1487-2

Document: Episodic/Focused SOAP Note Exemplar (Word document)

Document: Episodic/Focused SOAP Note Template (Word document)

Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical. Vital Signs and Pain Assessment Discussion Paper
• Chapter 13, “The Spine, Pelvis, and Extremities”

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. Vital Signs and Pain Assessment Discussion Paper