DISCUSSION: Assessing Musculoskeletal Pain| NURS 6512N-32

DISCUSSION: Assessing Musculoskeletal Pain| NURS 6512N-32

DISCUSSION: Assessing Musculoskeletal Pain| NURS 6512N-32

Musculoskeletal Episodic/Focused SOAP Note Template

Patient Information:

C.O. 42 Male Caucasian

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S.

CC “Back pain”

HPI: Patient is a 42-year-old Caucasian male who has had lower back pain for the past month. The pain sometimes radiates to his left leg. The pain is constant and cramping, occasionally sharp/stabbing and then radiates to left leg. Pain is rated 8/10 in terms of intensity. The pain is continuous. Sitting and bending exacerbates the pain. Pain medication and standing help to reduce the pain to 5/10 temporarily for a few hours but does not fully relieve the pain to 5/10 for a few hours, but then the pain returns. Occasional use of heating pad alleviates pain for small amount of time and then it returns. When pain radiates to left leg, some numbness and tingling to the associated extremity is also experienced.

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Current Medications: Lisinopril 20mg BID last taken 0900 this morning, Metformin 500mg BID last taken 0900 this morning, Acetaminophen 1000 mg TID for past month for pain control

Allergies: No known drug, food or environmental allergies

PMHx: current on all childhood immunizations, tetanus 10/2017, COVID 12/2019, 1/2020, flu 10/2022, no pneumonia vaccine noted. No surgical history. HTN diagnosed 1 year ago, DM2 diagnosed 10 years ago.

Soc Hx: Construction worker, runs heavy equipment. Workdays are usually 12 hours and are 6 days a week during the “busy season”. Hobbies include riding motocross, working on cars, and watching television. Married to his wife for 30 years. He has two children from this marriage, a n adult son and an adolescent daughter who lives at home with patient and his spouse. Smokes two packs of cigarettes daily and has smoked since he was 16 years old. Denies vaping, e-cigarettes, or smokeless tobacco. Denies alcohol use ever. Denies illicit drugs. Denies marijuana use.  States home has hardwired and carbon dioxide detectors. Feels safe in his home. Lives in a safe neighborhood. Feels support system is adequate. Uses seat belt while operating a motor vehicle and never texts or uses cell phone while operating a motor vehicle.

Fam Hx: Father is deceased at age 75 CVA, Parkinson’s, HTN, anxiety. Mother is living age 82, DM, HTN, TIA, Parkinson’s. PGM deceased old age 96 no noted medical history. PGF deceased, ETOH abuse, estranged and no information available. MGM deceased 75 CVA HTN, Parkinson’s. MGF deceased 80 MI, HTN. Oldest sister is alive aged 54, A-Fib, Parkinson’s, anxiety. Sister alive aged 50, MI, marijuana abuse. Son is alive 22 and lives nearby. Daughter is alive 17 and does not have a remarkable history.

ROS:

GENERAL:  denies unexplained weight loss or gain, fever, chills, weakness, or fatigue.

SKIN:  denies rashes or pruritis

GASTROINTESTINAL:  denies anorexia, nausea, vomiting or diarrhea. Denies abdominal pain. Denies blood in stool.

GENITOURINARY:  denies pain or burning on urination. Denies blood in urine. Denies incontinence. Denies pain to bilateral flanks.

NEURO:  denies headache, dizziness, syncope, paralysis, or ataxia. Admits to occasional intermittent numbness and tingling in his left lower extremity. Denies weakness to lower extremities. Denies foot drop.

MUSCULOSKELETAL:  Denies joint pain or stiffness. Admits to lower back pain that radiates into LLE.

O.

Vital Signs: BP 141/82; HR 98; RR 16; Temp 98.6; O2 98% on RA; Height 185 cm; Weight 74.84 kg; BMI 21.8

GENERAL:  AOx4; direct eye contact, pleasant and cooperative during assessment; no acute distress

SKIN:  appropriate for ethnicity; no tenting; warm and dry; no ecchymosis

GASTROINTESTINAL:  soft; symmetrical; no distention; bowel sounds present and normoactive to all 4 quadrants; no tenderness on light palpation; no masses on deep palpation; spleen unpalpable; Liver span dull to percussion, 1 cm below right coastal margin, 7 cm at midclavicular line; abdominal wall tympanic to percussion

GENITOURINARY:  bilateral kidneys unpalpable

NEURO:  gait symmetrical and steady; BUE sensation intact; LLE sensation intact; BLE sensation decreased.

MUSCULOSKELETAL:  no edema; ROM reduced with spine noted with flexion, extension, lateral bending, and rotation; equal 5/5 strength in neck, bilateral shoulders and BUE; equal 5/5 strength in bilateral hip flexors and BLE. Bilateral shoulders with full ROM with equal symmetry to shoulder shrug. Full ROM to R/L neck rotation.

Diagnostic results: if pain is less than 4 weeks and no high-risk condition no testing required. If
pain continues beyond 4 weeks, x-rays for fractures. CT scan for injuries to bones, muscles tissue, tendons, nerves, ligaments, and blood vessels. MRI, same as CT scan. Labs for infection. Nerve studies to see how nerve and muscle health are. 0

A.

Herniated intervertebral disk – L4-5 and S-1 radiating pain begins in lower back and radiates down inner side of leg to mid-thigh. Increases with sitting and bending. Decreases with standing.

Lumbosacral strain – aggravated by standing, relieved by resting and reclining.

Spinal stenosis – bilateral gradual onset that worsens with walking and standing

Arthritis  

Urinary tract infection

P.

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

References

John Hopkins Medicine. (2022). Radiculopathy. Retrieved from Health: https://www.hopkinsmedicine.org/health/conditions-and-diseases/radiculopathy

Rhoads, J. &. (2017). Differential Diagnosis for the Advanced Practice Nurse. New York: Springer Publishing Company.

Suneja, M. S. (2020). The Spine, Pelvis, and Extremities. In M. S. Suneja, DeGowin’s Diagnostic Examination (11 ed., pp. 527-619). New York: McGraw Hill.

Uphold, C. &. (2017). Low Back Problems, Acute. In C. &. Uphold, Clinical Guidelines in Family Practice (pp. 830-838). Gainesville, FL: Barmarrae Books.

RE: Review of Case Study 1 – Tanita Brock

Hello Tanita,Back pain can be mechanical or non-specific, ranging from mild to causing significant disability. Back pain, a common problem in the emergency room, has a broad range of etiologies depending on the patient population (Casiano et al.). I agree with your differential diagnoses. Two other potential diagnoses are spondylolisthesis and sciatica, a symptom of lumbar spinal disorder. Spondylolisthesis is a spinal condition that occurs when vertebrae move more than they should. This condition causes lower back pain. A vertebra slips out of place onto the vertebra below and can cause pain (Spondylolisthesis, n.d.). Sciatica is a nerve pain that a lumbar spinal disorder can cause. Sciatica is a nerve pain that travels along the sciatic nerve path and is often described as shooting or searing (Parker, 2019). This pain flares up when the sciatic nerve becomes irritated or pinched. Thank you for your informative post.References:

Casiano VE, Sarwan G, Dydyk AM, et al. (2022) Back Pain. National Library of Medicine Web site. Retrieved October 21, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK538173/

Parker, L. (2019). Is my pain sciatica or something else? Spine-health Web site. Retrieved October 21, 2022, from

Spondylolisthesis (n.d.). Cleveland Clinic Web site. Retrieved October 21, 2022, from

Hey Tanita,

I have enjoyed reading your post.  You mention some great diagnosis for the patient with lower pain.  Lower back pain is such a broad symptom that can range from some many issues. Lower pain back can be caused by many different issues, so further observation is important for a proper diagnosis.   “While nearly half of healthy, active people over age 60 experience lower back pain, according to a 2018 study published in the Journal of the American Geriatrics Society, such flare-ups aren’t necessarily an inevitable feature of aging” (Levine, 2019).

As described in the case study, the patient has a history of diabetes.  Diabetes can cause nerve damage resulting in pain in different areas of the body.  With the effects of continuous high blood sugar, different nerve damage such as peripheral, autonomic, proximal, and focal can occur as stated by the Center for Disease Control and Prevention in 2022.  Symptoms can range from numbness, weakness, increased pain in buttock, hip, thigh, stomach, etc.  Risk factors for nerve damage can include diabetes, age over 40 years old, overweigh, etc.  The patient will need further testing such as Xray, MRI, and CT scan to rule out this diagnosis as stated by the Mayo Clinic in 2022.

Reference

Centers for Disease Control and Prevention. (2022, June 20). Nerve Damage. Retrieved from The Center for Disease Control and Prevention.

Levine, H. (2019, February 1). Here’s what is causing your lower back pain? Retrieved from AARP: https://www.aarp.org/health/conditions-treatments/info-2019/habits-causing-lower-back-pain.html?cmp=KNC-DSO-COR-Health-Pain-NonBrand-Phrase-29895-Bing-HEALTH-ConditionsTreatments-ConditionsTreatments-LowerBackPain-Phrase-NonBrand&&msclkid=7b5af769caf31729

Mayo Clinic Staff. (2022, September 13). Sciatica. Retrieved from Mayo Clinic: https://www.mayoclinic.org/diseases-conditions/sciatica/diagnosis-treatment/drc-20377441

RE: Review of Case Study 1 – Response #2 – Mahala Hamblin

Hi Tanita,

I enjoyed your discussion post reviewing case study #1 and the differential diagnoses provided. However, further information is required to thoroughly examine and diagnose this patient. Depending on the length of time the patient has been experiencing this pain, it could be useful to obtain an Xray or CT scan to examine the condition further.

My primary diagnosis for this patient would be sciatic nerve pain due to the pain in the lower back traveling down the left leg. Often sciatic nerve pain is described as sharp, stabbing, jolting, shooting, and even throbbing (Cleveland Clinic, 2020). Typically, this pain is due to inflammation or pinching of a nerve in the lower back (Cleveland Clinic, 2020). To assess for this condition, it is important to perform several tests. The straight leg raise test will help pinpoint if there are any affected nerves or disks in the back (Cleveland Clinic, 2020). Another test to perform would be a spinal Xray to examine for fractures, infections, and even back problem (Cleveland Clinic, 2020).

A herniated vertebral disc is a great potential diagnosis for this patient because the patient can experience pain that may radiate down the legs and associated numbness. With a herniated vertebral disc, depending on the severity, patients may have no symptoms or may experience pain, tingling, burning, and numbness to the affected side (American Association of Neurological Surgeons, 2022). Further diagnostic testing is required to determine if this is an accurate diagnosis for the patient.

I also agree that spinal stenosis is a potential diagnosis for this patient. Spinal stenosis is the narrowing of the spinal canal and the pressure can result in lower back pain that radiates down the buttock into the thigh (Garrick, 2020). A common cause of spinal stenosis is arthritis, which is a potential cause of this diagnosis (Garrick, 2020).

The differential diagnosis of a urinary tract infection is unlikely based on the patient having pain that radiates down the leg. However, UTIs can cause lower back pain in some patients. However, most of the time, UTIs that do cause back pain will be described as mid-back pain and also radiate into the groin area (Center for Family Medicine, 2020). Therefore, it would be a good idea to obtain a urine sample to rule out infection to be safe.

References

American Association of Neurological Surgeons. (2022). Herniated Disc. Www.aans.org. https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Herniated-Disc?fbclid=IwAR3rC9ZFETlgTcCPevqZdw9RmMMR8dBY9HGrZncZwtBaSiD5Xp-AOuV-qWc

Center for Family Medicine. (2020, March 4). Can A UTI Cause Back Pain? Symptoms And Treatment Options. Center for Family Medicine. https://centerforfamilymedicine.com/general-health/can-a-uti-cause-back-pain-symptoms-and-treatment-options/?fbclid=IwAR2Wf7Y0jqaGi_mapYUnGD-W3E7xsjK5EvdPNCIvnGdqNfqMrduATtbw40U

Cleveland Clinic. (2020, March 25). Sciatica: Causes, Symptoms, Treatment, Prevention & Pain Relief. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/12792-sciatica#management-and-treatment

Garrick, N. (2020, January 2). Spinal Stenosis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. https://www.niams.nih.gov/health-topics/spinal-stenosis#:~:text=Symptoms%20of%20spinal%20stenosis%20in

Assessing Musculoskeletal Pain

 

Patient Initials: S.K              Age: 42 years old                             Gender: Male

SUBJECTIVE DATA:

Chief Complaint (CC): “Pain in my lower back for the past one month”

History of Present Illness (HPI): S.K is a 42-year-old Caucasian male patient who reported to the clinic with pain in his lower back that had lasted for about a month. he reports that the pain radiates to his left leg sometimes. The patient reports that the pain is worse when working, and is less disturbing when resting. He has been taking ibuprofen which he claims to provide minimal relief.

Location: lower back

Onset: about a month ago

Character: constant and sharp pain radiating to the left leg

Associated signs and symptoms: None

Timing: When handling strenuous work

Exacerbating/ relieving factors: Any movement worsens the pain. Resting and Ibuprofen provides minimal relief.

Severity: 7/10 on a pain scale

Medications:

  • Ibuprofen 800mg PO PRN for the back pain

Allergies:

No known environmental, food, or drug allergies.

 

Past Medical History (PMH):

Denies any history of a serious medical diagnosis

Past Surgical History (PSH):

Denies ever undergoing any surgical procedure in the past.

Sexual/Reproductive History:

Heterosexual

Personal/Social History:

Married with 3 children

Works in a book store downtown.

Has never smoked tobacco or marijuana.

Confirms taking 2 to 3 beers occasionally when with friends.

Immunization History:

Flu shot 17/2/2022

Covid Vaccine #1 2/1/2021 #2 3/1/2021 Moderna

All other immunization up to date

 

Significant Family History:

Mother- with HTN and DM

Father- with gout and kidney disease

Maternal grandmother- with kidney disease

Maternal grandfather-  died from a stroke

Paternal grandmother- with COPD

Paternal grandfather with CAD, HTN, and COPD.

He has 2 daughters and one son who are all healthy with no significant health complications.

 

Lifestyle:

The patient works in a bookstore downtown. He is happily married to a junior school teacher with 3 children. They live on the outskirts of the city in a 3 bedroom apartment in a safe neighborhood. The means of transport is good, with easily accessible fresh water and healthcare services. He tried as much as possible to eat a healthy diet together with his family. He walks the dog every evening for about a kilometer as a form of exercise. Uses seat belts when in the car, with safety equipment such as a first-aid kit available in their home. He is a strong church member and socializes with his friends mostly over the weekend.

 

Review of Systems:

General: No recent changes in body weight. Complains of pain in his lower back. Denies constipation, fatigue, chills, fever, or generalized body weakness.

HEENT: Head: No signs of trauma or headache reported. Eyes: Denies blurred vision, use of corrective lenses, excessive tearing, or redness. Ears: No tinnitus, itchiness, or hearing loss. Nose: no congestion, running nose, sinus problems, or nose bleeding. Throat & Mouth: No sore throat, coughing, swallowing difficulties, or dental problems. Neck: No tenderness, signs of injury, enlarged tonsils, or a history of disc disease or compression.

Respiratory: No wheezing, coughing, shortness of breath, or breathing difficulties.

CV: Denies chest pain, edema, PND, orthopnea, syncope, or palpitations. Dyspnea on exertion

GI: No abdominal tenderness, constipation, diarrhea, distention, changes in bowel movement, or jaundice.

GU: Denies incontinence, urinary frequency, hematuria, dysuria, or burning sensation when urinating.

MS: Reports lower back pain which sometimes radiates to the left leg. He rates the pain at 7/10 on a pain scale. The severity of the pain however worsens when walking or turning when sleeping. The patient confirms that the pain has lasted for about a month, making it harder to exhibit a full range of movement on the left leg. No numbness, swelling, or redness was reported.

Psych: Denies paranoia, hallucinations, delirium, suicidal ideation, mental disturbance, memory loss, anxiety or depression, or a history of psychosis.

Neuro: Reports back pain that radiates to the left leg. Denies vertigo, tremors, syncope, seizures, paresthesia, or transient paralysis.

Integument/Heme/Lymph: No bruising, ecchymosed, ulcers, lesions, or rashes. No signs of enlarged lymph nodes.

Endocrine: Denies heat intolerance, cold intolerance, polyuria, polyphagia, or polydipsia.

Allergic/Immunologic: Denies hay fever, urticaria, persistent infections, or HIV exposure.

 

OBJECTIVE DATA

 

Physical Exam:

Vital signs: B/P 140/96, left arm, sitting, regular cuff; P 88 and regular; T 98.9 Orally; RR 18; non-labored; Wt: 215 lbs; Ht: 5’8; BMI 32.69

General: The patient appears healthy, and well oriented in person, place, and time. Seems to be uncomfortable and in moderate pain.

HEENT: External ears normal, with no deformities or lesions. External nose normal with no deformities or lesions. Bilaterally clear canals. Intact tympanic membrane with good movement and no fluid. Grossly intact bilateral hearing. Normal nasal mucosa, septum and turbinates. Complete and good hygienic dentation.

Neck: Supple with no masses. Trachea midline, No thyroid nodules, tenderness, or masses.

Chest/Lungs: Bilaterally clear to auscultation. Tactile fremitus normal. No signs of egophony. Normal respiratory effort displayed with no use of accessory muscles.

Heart/Peripheral Vascular: S1, and S2, note. Normal cardiac rhythm with no murmur, gallop, or rubs.

ABD: Suprapubic surgical scar, obese, non-tender, soft, and non-distended abdomen with no masses.

Genital/Rectal: The patient did not consent to this examination.

Musculoskeletal: Low back pain noted, radiating to the left lower leg. No evidence of trauma affecting the area was noted. Tenderness increases with extension, flexion, and twisting. Limited ROM in the left leg.

Neuro: Cranial nerves: II – XII grossly intact; 2+, symmetric, reflexes.

 

Diagnostics/Lab Tests and Results:

CBC – To evaluate for spinal infections

CSF analysis- For suspected spinal infection or inflammatory etiologies

X-ray of the spine- for flexion-extension views to identify spondylolisthesis and spinal instability.

MRI of the spine- to assess for suspected myelopathy or radiculopathy.

Electromyography (EMG)- to confirm compressions caused by spinal stenosis or herniated disks (Urits et al., 2019).

ORDER A CUSTOMIZED, PLAGIARISM-FREE DISCUSSION: Assessing Musculoskeletal Pain| NURS 6512N-32 HERE

Assessment:

Differential Diagnosis (DDx):

  • Sciatica: This condition is characterized by pain that normally radiates along the sciatic nerve path, which branches from the patient’s lower back through to the buttocks and hip, and down to each leg (Kim et al., 2018). However, sciatica normally affects one side of the body. The patient in the provided case study presents with lower back pain that radiates to the left leg, which is a great indication of sciatica as the primary diagnosis.
  • Lumbar disc herniation: LDH is characterized by lower back pain and is common among adults between the age of 35 and 50 years. It normally results from changes in the structure of the lower lumbar spinal disk between the 4th and 5th vertebrae and between the 5th lumbar vertebra and the 1st sacral vertebra (Benzakour et al, 2019). Most patients normally present with symptoms such as lower back pain, radicular pain, limited trunk flexion, and weakness at the lumbosacral nerve roots distribution. The patient in the provided case study displayed lower back pain, however, an MRI of the spinal column is needed to confirm this diagnosis.
  • Lumbar spinal stenosis: LSS is associated with narrowing of the spinal canal located in the lower back resulting in pain. Stenosis causes pressure on the patient’s spinal cord or nerves connecting the spinal column and the muscles (Deer et al., 2019). As such patients will present with lower back pain just like the one in the provided case study. However physical examination is required to assess for the presence of loss of sensation, abnormal reflexes, and weakness to confirm this diagnosis.
  • Lumbar muscle strain: LMS is described as an injury to the lower back characterized by mild to moderate lower back pain. The injury can lead to damage to the muscle or tendons causing spasms and soreness (Urits et al., 2019). An x-ray is however needed to confirm the impact of the injury on the tendon or muscle to confirm the diagnosis
  • Ankylosing spondylitis: This is an inflammatory disorder, that can lead to some of the spinal bones fusing over time. It is characterized by pain in the joints and the back (Ogdie et al., 2019). Symptoms normally appear early in life, including reduced flexion of the spine. The patient only presented with back pain which radiates to the left leg with no joint pain or reduced flexion of the spine.

Primary Diagnoses:

1.) Sciatica

PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]

References

Benzakour, T., Igoumenou, V., Mavrogenis, A. F., & Benzakour, A. (2019). Current concepts for lumbar disc herniation. International orthopedics43(4), 841-851. https://doi.org/10.1007/s00264-018-4247-6

Deer, T. R., Grider, J. S., Pope, J. E., Falowski, S., Lamer, T. J., Calodney, A., … & Mekhail, N. (2019). The MIST guidelines: the Lumbar Spinal Stenosis Consensus Group guidelines for minimally invasive spine treatment. Pain Practice19(3), 250-274.

Kim, J. H., van Rijn, R. M., van Tulder, M. W., Koes, B. W., de Boer, M. R., Ginai, A. Z., … & Verhagen, A. P. (2018). Diagnostic accuracy of diagnostic imaging for lumbar disc herniation in adults with low back pain or sciatica is unknown; a systematic review. Chiropractic & manual therapies26(1), 1-14. https://doi.org/10.1186/s12998-018-0207-x

Ogdie, A., Benjamin Nowell, W., Reynolds, R., Gavigan, K., Venkatachalam, S., de la Cruz, M., … & Park, Y. (2019). Real-world patient experience on the path to diagnosis of ankylosing spondylitis. Rheumatology and Therapy6(2), 255-267. https://doi.org/10.1007/s40744-019-0153-7

Urits, I., Burshtein, A., Sharma, M., Testa, L., Gold, P. A., Orhurhu, V., … & Kaye, A. D. (2019). Low back pain, a comprehensive review: pathophysiology, diagnosis, and treatment. Current pain and headache reports23(3), 1-10. https://doi.org/10.1007/s11916-019-0757-1

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