Assignment; Assessing Musculoskeletal Pain Essay

Assignment; Assessing Musculoskeletal Pain Essay

Assignment; Assessing Musculoskeletal Pain Essay

Assignment; Assessing Musculoskeletal Pain Sample Essay

Episodic/Focused SOAP Note Template

Patient Information:

Initials: P.L                 Age: 42 years old                    Sex: Male                    Race: Caucasian

S.

CC: “I have had lower back pain for a month now.”

HPI: P.L., a 42-year-old man, claims to have been experiencing lower back pain for the past month. Occasionally, the sensation of pain extends to the patient’s left lower extremity. The patient asserts that the level of pain is more pronounced during periods of work and comparatively less during periods of relaxation. The patient has been administering ibuprofen, asserting that it provides only partial relief from his symptoms.

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Location: lower back

Onset: About one month ago

Character: severe pain that gradually spreads to the left leg that never goes away

Associated signs and symptoms: None

Timing: handling a challenging job

Exacerbating/ relieving factors: Movement makes the pain worse. Resting and ibuprofen do not even provide much help.

Severity: 7/10 on a pain scale

Current Medications: To alleviate back pain, the administration of ibuprofen at a dosage of 800 mg orally as needed is used.

Allergies: There are no documented medication, food, or environmental allergies.

PMHx: denies knowing a critical medical diagnosis in the past.

Past Surgical History (PSH): denies ever having surgery.

Sexual/Reproductive History: heterosexual; just one partner in sex. denies having ever had a history of STDs

Immunization History: immunization against influenza on February 17, 2023; Covid Vaccines #1 and #2 (dated 2 and 3 February 2021) by Moderna; The other immunizations are all up to date.

Soc Hx: married with three children. works at a bookstore in the city. has never smoked cigarettes or marijuana. admits to having two or three beers with friends on occasion. The patient works in a bookstore in the heart of the city. He is married to an elementary school teacher and they have three children. They feel secure in their three-bedroom suburban apartment. The transportation system is reliable, and essential services like clean water and hospitals are easily accessible. He exerted great effort to ensure that his loved ones ate well. He exercises by walking the dog on a one-kilometer walk every night. He takes safety precautions by always using seat belts and keeping first aid kits in the house. He devotes most of his weekends to attending church and socializing with friends.

Fam Hx:

Mother- diabetes and hypertension at age 65

Father- 69 years old with hyperlipidemia and COPD

Maternal grandmother- died of hypertension at the age of 75

Maternal grandfather- died at the age of 73 after a heart attack.

Paternal grandmother- died of GOUT at the age of 83

Paternal grandfather- died at age 69 from obesity, hyperlipidemia, hypertension, and asthma.

He has one healthy son and two healthy daughters, none of whom have any significant medical conditions.

ROS:

GENERAL: denies most recent weight changes. He says his lower back hurts. denies having diarrhea, being worn out, having chills or a fever, or feeling weak in general.

HEENT: Head: denies having any bumps or bruises. Denies having red eyes, excessive weeping, or wearing glasses. No discomfort or inflammation in the ears. denies having sinus issues. denies having cold or dental issues.

NECK: denies having big tonsils.

RESPIRATORY: denies the presence of wheezing, a chesty cough, or breathing problems.

CARDIOVASCULAR: denies experiencing chest discomfort, edema, orthopnea, syncope, or palpitations. dyspnea brought on by exertion

ABDOMINAL: denies experiencing diarrhea, constipation, distention, or stomach discomfort.

GENITOURINARY: denies having frequent or hot urination, hematuria, urine retention, or incontinence.

MUSCULOSKELETAL: There have been complaints of lower back pain that sometimes affects the left leg. He rates the pain a seven on a scale of one to ten. But the pain increases if you move or turn while you’re still sleeping. The patient acknowledges that the soreness has been there for about a month and has made it more difficult to completely extend the left leg. denies any swelling, redness, or numbness.

PSYCHIATRIC: denies a history of hallucinations, delusions, delirium, self-harm, mental illness, memory loss, worry, or grief.

NEUROLOGICAL: The backache is spreading to the left leg. denies feeling dizziness, vertigo, tremors, syncope, paresthesia, transient paralysis, or trembling.

SKIN/HEME/LYMPH: denies having any bumps, lesions, ulcers, or ecchymosis. denies any evidence of enlarged lymph nodes.

ENDOCRINE: denies having polydipsia, polyuria, or polyphagia.

ALLERGIC/IMMUNOLOGIC: denies having hay fever, urticaria, reoccurring infections, or has had contact with HIV.

O.

Physical Exam:

Vital signs: P 89 and regular; T 99.9 orally; RR 19; non-labored; B/P 141/97, left arm, seated; regular cuff; Wt. 213 lbs., 5’9″ tall, with a BMI of 31.45

General: The patient seems to be in excellent health and has a positive sense of time, location, and other people. looks to be uneasy.

HEENT: external ears that are normal, unaltered, and in good health. On the exterior of the nose, there are no lesions or anomalies. bilaterally clear canals. The tympanic membrane is still there, fluid-free, and freely moving. Both ears’ hearing is mostly unaltered. normal mucosa, turbinates, and septum in the nose. Dentition that is complete and hygienically sound.

Neck: Supple and uncluttered. Midline trachea, no bumps, pain, or thyroid nodules.

Chest/Lungs: Auscultation reveals bilateral clarity. normal fremitus tactile. Egophony is not evident. The auxiliary muscles are not used, and normal breathing effort is evident.

Heart/peripheral vascular: S1 and S2 are present. Normal heartbeat; no rubbing, gallop, or murmur.

Gastrointestinal: Obese with a suprapubic surgical scar and an abdomen that is soft, non-dilated, and almost painful.

Genital/Rectal: The patient objected to being examined.

Musculoskeletal: A low back pain that radiates down the left lower leg is felt. There were no indications that the area had been harmed. Tenderness increases with an extension, flexion, and twist. reduced range of motion in the leg.

Neuro: With 2+ symmetric reflexes, the cranial nerves II–XII are mostly unharmed.

Diagnostics/Lab Tests and Results: CBC was ordered to look for spine infections. Examining the CSF for any signs of inflammation or spinal infections. Spinal instability and spondylolisthesis may be identified via an X-ray of the spine with images in the flexion and extension positions. MRI of the spine to look for any myelopathy or radiculopathy that could be present. To confirm compressions caused by spinal stenosis or herniated disks, electromyography (EMG) is used (Urits et al., 2019).

A.

Differential Diagnoses

• Sciatica: Han et al. (2023) have documented that this particular ailment is distinguished by the presence of pain that commonly extends along the lower extremities and follows the trajectory of the sciatic nerve, which originates from the lumbar region and courses through the gluteal and hip regions. Sciatica commonly exhibits unilateral manifestation in the human body. The presented case study involves a patient who expresses concerns regarding discomfort in the lower back that radiates down the left leg. This symptomatology strongly suggests that sciatica is the primary diagnosis.
• Lumbar disc herniation: A common sign of LDH in people aged 35 to 50 is lower back discomfort. It often results from structural changes in the lower lumbar spinal disk between the fourth and fifth vertebrae, as well as between the 5th lumbar vertebra and the 1st sacral vertebra, according to Benzakour et al. (2019). Most patients often experience symptoms such as lower back pain, radicular pain, limited trunk flexion, and weakness where the lumbosacral nerve roots are distributed. Despite the patient’s complaints of lower back pain in the provided case study, a spinal column MRI is necessary to establish this diagnosis.
• Lumbar spinal stenosis: Lumbar spinal stenosis (LSS) is distinguished by the occurrence of a pain-inducing constriction within the spinal canal located in the lower back region. Deer et al. (2019) assert that the condition known as stenosis exerts compression on either the spinal cord or the nerves responsible for connecting the spinal column with the muscles. Consequently, individuals may present with lumbar discomfort akin to the illustrative case study. To establish the diagnosis, it is imperative to conduct a comprehensive physical examination to assess the presence of muscular weakness, abnormal reflexes, and sensory deficits.
• Lumbar muscle strain: The LMS condition is classified as a type of lower back injury that results in mild to moderate discomfort in the lower back region. According to Urits et al. (2019), the occurrence of an injury has the potential to induce muscular or tendon damage, leading to the manifestation of spasms and pain. To ascertain the diagnosis and evaluate the impact of the injury on the tendon or muscle, it is necessary to obtain an X-ray.
• Ankylosing spondylitis: This pathologic condition possesses the capability to induce the progressive amalgamation of multiple vertebral bodies within the spinal column. The characteristic symptoms of the condition include joint and back pain (Ogdie et al., 2019). Early in childhood, a common symptom that frequently presents itself is a decrease in spinal flexion. The patient presented with a complaint of back pain radiating down the left leg, without any reported joint discomfort or reduced spinal flexibility.

Primary Diagnoses:

1.) Sciatica

References

Benzakour, T., Igoumenou, V., Mavrogenis, A. F., & Benzakour, A. (2019). Current concepts for lumbar disc herniation. International Orthopedics, 43(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 Practice, 19(3), 250-274. https://doi.org/10.1111/papr.12744

Han, C. S., Hancock, M. J., Sharma, S., Sharma, S., Harris, I. A., Cohen, S. P., Magnussen, J., Maher, C. G., & Traeger, A. C. (2023). Low back pain of disc, sacroiliac joint, or facet joint origin: a diagnostic accuracy systematic review. EClinicalMedicine, 59, 101960. https://doi.org/10.1016/j.eclinm.2023.101960

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 Therapy, 6(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 reports, 23(3), 1-10. https://doi.org/10.1007/s11916-019-0757-1

BUY A CUSTOM PAPER HERE ON; Assignment; Assessing Musculoskeletal Pain Essay

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?

• Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
• Review the following case studies:

Case 1: Back Pain

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?

Case 2: 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. 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?

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? 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 five possible conditions that may be considered in a differential diagnosis for the patient.
• 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.