Assessing Musculoskeletal Pain Essay
Discussion 8 Response
Discussion 1
The condition I would reject in this case is Osteoarthritis. Although the condition manifests mainly as low back pain, and it affects people who are older than 40 years, the patient does not show more signs of osteoarthritis (Chen et al., 2017). Since the patient is still in the early 40 years, it is hard for them to be affected more by this condition; hence it is better to concentrate on other conditions. The most likely condition is Degenerative Disc Disease (DDD). According to Parenteau et al. (2021), Degenerative Disc Disease is linked to aging and wear and tear. Following this, the patient might suffer from this as they become older and their vertebrae continue to lose their functionality (Parenteau et al., 2021). This, therefore, leads to fragmentation, something that may be causing back pain. Since DDD is one of the leading causes of severe back pain, I believe that the patient maybe suffering from this.
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References
Chen, D., Shen, J., Zhao, W., Wang, T., Han, L., Hamilton, J. L., & Im, H. (2017). Osteoarthritis: Toward a Comprehensive Understanding of Pathological Mechanism. Bone Research, 5(1). https://doi.org/10.1038/boneres.2016.44
Parenteau, C. S., Lau, E. C., Campbell, I. C., & Courtney, A. (2021). Prevalence of Spine Degeneration Diagnosis by Type, Age, Gender, and Obesity using Medicare Data. Scientific Reports, 11(1). https://doi.org/10.1038/s41598-021-84724-6
Discussion 2
The condition I would reject is the tibial fracture. Although the patient is athletic, they are still young and do not engage in very intense physical exercises. As seen, the pain has not worsened with time and use of the knee; hence the probability of them suffering from tibial stress is lower. Besides, the patient is too young to suffer from this as the condition is more common in adult patients and female patients (Chung et al., 2019). The most likely condition is a meniscus injury. In this case, the patient explains that the pain is gradual, hence it might go unnoticed. Besides, the pain might have started a long time ago without the patient noticing and it has increased gradually (Bhan, 2020). Since the patient is an athlete, I agree that they might experience high levels of stress at the knee as they exercise. I like your discussion and how you have explained the different conditions and given possible explanations.
References
Bhan, K. (2020). Meniscal tears: Current understanding, diagnosis, and management. Cureus. https://doi.org/10.7759/cureus.8590
Chung, J. S., Sabatino, M. J., Fletcher, A. L., & Ellis, H. B. (2019). Concurrent Bilateral Anterior Tibial Stress Fractures and Vitamin D Deficiency in an Adolescent Female Athlete: Treatment with Early Surgical Intervention. Frontiers in Pediatrics, 7. https://doi.org/10.3389/fped.2019.00397
Discussion 1
Patient Information: Initials B.L, Age 42, Sex Male , Race Caucasian
Subjective Data
CC (chief complaint) “Pain in lower back for past month that sometimes radiates to left leg”.
HPI: A 42-year-old Caucasian male arrives at the clinic complaining of lower back pain. Patient reports having experienced symptoms for the past month. The patient states that the pain sometimes radiates to his left leg. He claims it makes it difficult for him to sleep at night and interferes with his everyday duties. He has been using Ibuprofen 400mg OTC for two weeks to help relieve the pain. He claims to be more exhausted than usual because he wakes up numerous times during the night due to pain. He claims that sitting and bending over makes the pain worse, but that standing or sleeping flat and taking ibuprofen helps. He rates the pain as a 5/10, increasing to an 8/10 with activity.
Current Medications: Ibuprofen 400mg PO Q6H PRN pain
Allergies: No allergies to medications, latex, food, animals, or environmental allergies
PMHx: No significant diseases or illnesses. No history of hospitalizations. No previous fractures or trauma reported. Reports a good appetite. Generally sleeps well, but recent back pain has prevented him from sleeping comfortably. Current with Immunizations. Denies receiving the Influenza vaccine.
Soc Hx: Currently works in construction. Patient lives with his wife and children in a single home. Has been married for 20 years and has 2 children ages 10 and 15. Denies smoking, and reports drinking alcohol occasionally 1-2 beers monthly. He denies illicit drug use. He reports a healthy lifestyle including lifting weights 3 times a week and reports eating a high protein and low carb diet but does eat out once a week. Pt enjoys bike riding. He reports having access to health care through his wife’s employer.
Fam Hx:
Mother: High cholesterol
Father-: HTN
Paternal Grandfather: HTN
Paternal Grandmother: Diabetes type 2
Maternal Grandmother: High cholesterol
Maternal Grandfather: CAD, Alcoholism
Brother: Obese no medical conditions
Sister: Asthma
Son: No medical conditions
Daughter: No medical conditions
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ROS:
GENERAL: Alert and oriented x4, presents well nourished and groomed. Reports discomfort with back pain. Denies fever, chills, lightheadedness, weakness, or fatigue. Denes recent weight loss or changes in appetite.
HEENT: Denies any vision loss or double vision. Denies headaches or hx of seizures. Denies hearing loss, sneezing, congestion, runny nose or cough.
SKIN: No rashes or itching. No moles or abnormal findings.
CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema
RESPIRATORY: Denies any trouble breathing. No shortness of breath or coughing.
GASTROINTESTINAL: Denies any changes in appetite or weight. No nausea/vomiting, no constipation/diarrhea. No abdominal pain
GENITOURINARY: No urinary difficulties. No dysuria, and no incontinence. No changes in urinary patterns
NEUROLOGICAL: No weakness. No numbness or tingling. No paresthesia. No changes in urinary and bowel patterns and controls
MUSCULOSKELETAL: Reports back pain that radiates sometimes to left leg. Reports inability to bend, flex, or twist due to pain. Denies recent falls or trauma
LYMPHATICS: No enlarged nodes.
PSYCHIATRIC: Denies history of depression or anxiety.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
Vital signs: BP 140/69, Pulse 82, T 36.4 Orally; RR 18 non-labored; ,Wt: 220 lbs; Ht: 6’3”; BMI: 27.
GENERAL: Awake, alert, and oriented x4, well-groomed and well-nourished, patient appears uncomfortable and in pain, with facial grimacing upon movement, repeatedly changing chair position. No temperature, no recent weight changes, denies incontinence, paresthesias, tingling, and numbness.
HEENT: PERRLA, normal conjunctiva, mucous membranes moist.
Neck: Supple, no JVD noted, no bruits. Symmetric, no abnormal findings.
Chest/Lungs: Clear to auscultation in all lung fields.
Cardiovascular: Regular rate and rhythm. No murmur, rub, or gallops noted. Auscultated S1, S2, regular rhythm. No S3 or S4 sounds noted. Denies chest pain or palpitations. + 2 dorsal pedis, + 2 posterior tibial, and + 2 radial pulses; blood pressure measured on both arms is comparable; femoral and brachial pulses are similarly comparable; no abdominal bruit heard. No edema noted.
Abdomen: Bowel sounds present in all 4 quadrants, non-tender, soft, round, no rebound tenderness or guarding noted.
GASTROINTESTINAL: No nausea or vomiting. Last Bowel movement was yesterday. No diarrhea, no constipation. No changes in bowel patterns. Abdomen is soft and non-tender to palpation.
GENITOURINARY: Genitalia not examined at this time. No dysuria, and no incontinence. Denies changes in urinary patterns, denies incontinence.
MUSCULOSKELETAL: Low back pain radiating to the left lower extremity. No indication of trauma to the affected area. Pain increases with flexion, extension, and twisting. Reduced mobility due to pain. Positive test for straight leg raise at 45 degrees; negative test for hip extension. No deviations in the curvatures of the spinal column. Noted difficulties with toe walking, but none with heel walking. No motor weakness.
NEUROLOGICAL: A/O x4, calm and cooperative. Mood and affect are appropriate. Upper and lower extremity motor 5/5. Superficial pain not intact at the left lateral portion of the 5th toe; protective sensation intact. 1/4 Achilles reflex; all other 2/4.
LYMPHATICS: No enlarged lymph nodes palpated
Skin: No rashes or abnormal findings.
Diagnostic results:
CBC and sedimentation rate should be done if tumor, infection, or abscess is suspected (Perina,
2017).
X-Ray: Computed tomography (CT) or CT myelography is the next-best diagnostic for evaluating the presence of lumbar disc herniation in patients who are unable to have an MRI due to contraindications or for whom an MRI is inconclusive. Electrodiagnostic studies can also diagnose nerve root compression, although they cannot differentiate between lumbar disc herniation and other forms of nerve root compression. X-rays could be useful for diagnosing or ruling out osteoarthritis ( Allegri et al., 2016).
MRI: MRI of the lumbar spine should be explored for patients with warning signs. Suspecting a severe underlying condition, such as cauda equine syndrome, malignancy, or infection (Perina, 2017). Our past and physical assessment have eliminated these problems. Several studies have demonstrated that magnetic resonance imaging (MRI) is a highly sensitive diagnostic tool for identifying structural abnormalities (Yousif et al., 2020). Lumbar disc herniation can be diagnosed provisionally based on presenting symptoms, but correlation with an MRI is required to confirm the diagnosis (Koh et al., 2017)
A.
Differential Diagnoses
Lumbar disc herniation: Lumbar disc herniation (LDH) is defined as the prolapse of the nucleus pulposus through a defect in the annulus fibrosus forming the circumferential rim of the disc (Wang et al., 2019). LDH is a common cause of lower back pain and results in many emergency room and clinical visits each year. Several alterations in the biology of the intervertebral disc are believed to contribute to the development of LDH, with genetics playing a crucial role. Symptoms and signs include radicular pain, sensory anomalies, focal paresis, restricted trunk flexion, and an increase in leg pain with straining. Magnetic resonance imaging (MRI) is the gold standard for imaging to confirm suspected LDH, with a diagnosis accuracy of 97%. (Amin et al., 2017).
Spinal Stenosis: Typically, multiple factors contribute to lumbar spinal stenosis. Degenerative arthritis of the spine and thickening of the ligamentum flavum are the most common causes, affecting people over 60 years of age (Wheeler et al., 2018). Lumbar spinal stenosis is characterized by ambulation-induced pain in the calf and distal lower extremities that resolves with sitting or leaning forward (pseudo or neurogenic claudication). Other symptoms of lumbar spinal stenosis may include back pain, sensory loss, and limb weakness, though many individuals may present with a normal neurologic examination (Wheeler et al., 2018).
Ankylosing spondylitis: Ankylosing spondylitis affects around 0.5 percent of people who appear in primary care settings with back pain; it is most typically diagnosed in men under the age of 40 (Wheeler et al., 2018).
Osteoarthritis: This condition can also manifest as low back pain, and its beginning is typically after age 40, with pain being present during activity and relieved by rest; however, it develops gradually over time (Ball et al., 2019).
Degenerative disc disease (DDD): DDD is linked to aging as well as typical wear and tear. DDD refers to the decrease of cushioning between the vertebrae, which can lead to herniation and fragmentation. It is one of the leading causes of chronic back pain (Fakhoury & Dowling, 2022).
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Allegri, M., Montella, S., Salici, F., Valente, A., Marchesini, M., Compagnone, C., Baciarello, M., Manferdini, M. E., & Fanelli, G. (2016). Mechanisms of low back pain: a
guide for diagnosis and therapy. F1000Research, 5, F1000 Faculty Rev-1530. https://doi.org/10.12688/f1000research.8105.2
Amin, R. M.,Andrade, N. S., &Neuman, B. J. (2017). Lumbar Disc Herniation.CurrentReviews in Musculoskeletal Medicine, (4),
507.https://doi-org.ezp.waldenulibrary.org/10.1007/s12178-017-9441-4
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.
Fakhoury J, Dowling TJ. Cervical Degenerative Disc Disease. [Updated 2022 Apr 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022
Jan-. https://www.ncbi.nlm.nih.gov/books/NBK560772/
Koh, Z., Lin, S., & Hey, H. (2017). Lumbar disc herniation presenting with contralateral symptoms: a case report. Journal of Spine Surgery, 3(1),
92-94. http://dx.doi.org/10.21037/jss..2017.03.06
Perina, D. G. (2017). Mechanical Back Pain Workup. Medscape. https://emedicine.medscape.com/article/822462-workup ?
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Wang, F., Dong, Z., Li, Y.-P.,Miao, D.-C., Wang, L.-F., &Shen, Y. (2019). Wedge-shapedvertebrae is a risk factor for symptomatic upper lumbar disc herniation. Journalof
Orthopaedic Surgery and Research,14(1). https://doi org.ezp.waldenulibrary.org/10.1186/s13018-019-1314-7
Wheeler, S. G., Wipf, J. E., Staiger, T. O., Deyo, R. A., Jarvik, J. G. (2018). Evaluation of low back pain in adults. UpToDate. https://www.uptodate.com/contents/evaluation-
Yousif, S., Musa, A., Ahmed, A., & Abdelhai, A. (2020). Correlation between findings in physical examination, magnetic resonance imaging, and nerve conduction studies
in lumbosacral radiculopathy caused by lumbar intervertebral disc herniation. Advances in Orthopedics, 2020. http://dx.doi.org/10.1155/2020/9719813
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Discussion 2
Patient Information:
JS 15 Year Caucasian Old Male
S.
CC: Bilateral Knee Pain
HPI: JS is a 15-Year-Old Caucasian male patient who presents with his parents today with bilateral knee pain. The pain is intermittent, dull in nature, and rated at a 5/10. He states that the pain began a week ago and that there has been no trauma to either knee. There is also a click when flexing the knee and describes a catching sensation underneath his patella. The pain has not gotten worse over the last week but has not improved either.
Current Medications: Tylenol 650 mg oral tablet q 6 hours for knee pain
EpiPen PRN for peanut allergy
Allergies: Allergic to peanuts
NKDA
PMHx: Up to date on all immunization
One previous episode of anaphylaxis as a child
Soc Hx: The patient lives at home with his parents. He has one younger brother. Denies any alcohol, tobacco, or illicit drug use. He attends the local public high school where he plays football and baseball.
Fam Hx: Father has a history of HTN. Mother has a history of DMII. Maternal grandmother had HTN, DMII, HLD. Maternal grandfather has HTN and HLD. Paternal grandmother has DMII. Paternal grandfather has DMII, HTN, HDL, history of an MI.
ROS:
GENERAL: The patient denies any fever, chills, fatigue, or weakness.
HEENT: Reports no headache. No vision or hearing issues. No nose drainage or congestion. No throat soreness or trouble swallowing.
SKIN: No rashes, lesions, bruises, or scars.
CARDIOVASCULAR: No chest pain or palpitations. No syncope. No extremity swelling or edema. No extremity numbness or tingling.
RESPIRATORY: No cough or trouble breathing.
GASTROINTESTINAL: Reports no issues with bowel health or bowel patterns. No diarrhea, nausea, or vomiting.
GENITOURINARY: No difficulty urination. No frequency, hesitancy, or burning with urination.
NEUROLOGICAL: No headache, dizziness, syncope, or seizure activity.
MUSCULOSKELETAL: Dull pain located in knees bilaterally. Pain is located “all over” the knee. States he sometimes feels a “clicking” when he bends his knee. States he can move the knee with no issues and that it is not swollen.
HEMATOLOGIC: No easy bruising or bleeding.
LYMPHATICS: Reports no enlargement of lymph nodes.
PSYCHIATRIC: States he sometimes feels stressed over managing school and athletics but reports no anxiety or depression.
ENDOCRINOLOGIC: No polydipsia, polyphagia, or polyuria.
ALLERGIES: History of peanut allergy.
O.
Physical exam: Upon inspecting the patient’s knees they appear symmetrical and without swelling. No erythema or skin discoloration is present. No apparent masses or disfigurement. Palpation revealed tenderness to the lateral right and left knee. A catch was felt in the knee when passively extending the flexing the knee bilaterally. With the patient’s knee at 10 degrees while supine the lateral and medial ligaments were palpated with out pain. Lachman’s Test showed no movement of the tibial head suggesting no injury to the ACL or PCL. McMurry Test performed and a clicking was felt in both knees as well as pain. The Apley Test was performed, and pain was felt with compression (Suneja, et al, 2020).
Diagnostic results: An Xray and Inflammatory markers are to be ordered and completed first. The Xray will assess for any fractures that may require immediate intervention. The inflammatory markers, such as rheumatoid factor are ordered to rule out Rheumatoid Arthritis, which is an unlikely cause, but can cause the pain that the patient is experiencing (McCance and Heuther, 2019). MRI and CT scans can be useful, as they can identify structural issues with the knee such as injuries to tendons and ligaments. However, MRIs and CT scans are usually reserved for chronic pain that has persisted despite treatment or for acute traumatic incidents (Blunt, Jonas, and Change, 2018).
A.
Differential Diagnoses
- Meniscus Injury
- Anserine Bursitis
- Tendonitis
- Tibial Stress Fracture
- Rheumatoid Arthritis
Presumptive Diagnosis: Meniscus Injury
The patient experienced a positive McMurray and Apley test, which are used to test specifically for meniscus injuries. Also, the trauma associated with a meniscus injury is often slight enough to go unnoticed. Which would explain why the pain started gradually. An injury to the meniscus would also explain the clicking and catching felt in the patient’s knee (Suneja, et al, 2020). Given that the patient is an athlete, it is possible that high levels of stress to the knee caused by exercise would cause tendonitis or bursitis. However, the pain is usually localized to a specific tendon and mobility can often be limited in tendonitis, which it is not in the patient. With bursitis, movement is not limited, and the pain can be simular to what the patient is experiencing. If it were not for the positive McMurray and Apley test this could be the presumptive diagnosis (McCance and Heuther, 2019).
A tibial stress fracture could also be common in young patient’s who are athletes, and the pain is also described as dull, which is how the patient describes his pain. However, the pain becomes progressively worse with time and use of the knee, which it has not with the patient. Rheumatoid Arthritis is the least likely of the possible diagnosis. It is more common in adult patients and in female patients and is most common in smaller joints. However, symmetrical joint pain is common with RA so it should be ruled out (Suneja, et al, 2020).
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Bunt, C., Jonas, C., Chang, J. (2018). Knee Pain in Adults and Adolescents: The Initial Evaluation. American Family Physician. 98(9). Retrieved October 19 2022, from https://www.aafp.org/pubs/afp/issues/2018/1101/p576.html.
McCance, K., Huether, S. (2019). Pathophysiology: The Biologic Basis for Disease in Adults and Children. 8th ed. Elsevier Publishing.
Suneja, M., Szot, J., LeBlond, R., Brown, D. (2022). DeGowin’s Diagnostic Examination. 11th ed. McGraw Hill Publishing.
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